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Kidney Transplant Services

Date: 12-30-2016

Emergency Medical Assistance provides coverage for kidney transplants to eligible recipients who are currently receiving dialysis services and are potential candidates for a kidney transplant through an approved Emergency Medical Assistance (EMA) Care Plan Certification (CPC) Request. EMA kidney transplant coverage is outlined in Minn. Statutes §256B.06, Subd4 (j) (3). This benefit became effective July 1, 2016.

Emergency Medical Assistance provides coverage for pre-transplant evaluation and care, transplant surgery, and post-transplant related care for 12 months when all of the following conditions are met:

  • • Effective dates of services on or after July 1, 2016
  • • Approved through an EMCA CPC
  • • Pre-transplant evaluation prior authorization (PA) approved
  • • Transplant inpatient hospital authorization (IHA) approved
  • • Meet criteria listed under Transplant Services on the Physician Professional Services section and are authorized by the medical review agent according to the requirements listed on the Transplant Authorization Code List, in addition to the CPC
  • • Must be performed in a hospital that meets the United Network for Organ Sharing (UNOS) criteria and is a participating provider for the Medicare program
  • Noncovered procedure - pre-emptive kidney transplant
    Pre-emptive kidney transplants are not covered under EMA.

    Pre-transplant approved diagnoses
    If the recipient currently has a diagnosis of a secondary condition that is caused by end stage renal disease (ESRD) and that presents an immediate threat to the person’s health, bodily function or bodily organs, the additional diagnoses is certified in conjunction with the dialysis and transplant diagnoses.

    EMA CPC date spans for kidney transplant

  • • EMA CPC requests for recipients awaiting an approved kidney transplant are typically approved for 12 months. If the recipient has not been transplanted during that year, a new EMA CPC would be required and typically approved for a 12 month period.
  • • EMA CPC requests for the kidney transplant and initial post-transplant period are typically approved for 12 months.
  • • Care beyond 12 months post-transplant must meet the EMA CPC guidelines for approval of coverage.
  • In cases where the kidney is acquired from a living donor, the charges are to be billed under the EMA recipient’s identification number. These charges include:

  • • Medical evaluation, physician charges and hospital charges
  • • Post-operative charges for six months post-donation of organ
  • • Post-operative complications are covered only if directly attributable to the donation surgery and the transplant occurs
  • • Complications that arise after the date of the donor’s discharge will be billed under the recipient’s health insurance number, this includes facility and physician service charges
  • • Claims up to six months post-donation of organ are billed using the recipient’s health insurance claim number
  • Prior authorization
    The physician is required to submit the Medical Prior Authorization (PA) for Pre-Kidney Transplant Evaluation and the Inpatient Hospital Authorization (IHA) forms for the kidney transplant to KEPRO, the authorization medical review agent.

    The transplant facility may request documentation of the PA approval from the physician's office or by calling the MHCP Provider Call Center at 651-431-2700 or 800-366-5411.

    When submitting the initial EMA CPC, the provider is required to include the following:

  • a. Statement of intended kidney transplant for the recipient
  • b. Transplant facility or program
  • c. Timeframe for pre-transplant evaluation
  • When submitting the PA for the pre-kidney transplant evaluation, the physician must include the following:

  • a. Timeframe for the pre-transplant evaluation
  • b. Transplant facility or program
  • Note: This PA will remain in a non-approved status until a transplant occurs.

    When submitting the request for inpatient hospital authorization (IHA) for kidney transplant, the provider must include the following information:

  • a. Transplant facility or program
  • b. Transplant date
  • c. Provider Information
  • Note: This prior authorization in a non-approved status until the transplant occurs.

    Following completion of the kidney transplant, both the pre-kidney transplant PA and the kidney transplant PA will be approved.

    If the intent is to perform the kidney transplant in an out-of-state facility, this must be noted on both the pre-kidney transplant evaluation PA and kidney transplant PA. Both PAs must be submitted prior to care being rendered. Please refer to the instructions in the MHCP Authorization policy for out-of-state services.

    If the donor kidney is harvested at a location outside of Minnesota or its local trade area by an out-of-state provider, a medical prior authorization must be obtained prior to the services being provided.

    If a living donor travels from another state to Minnesota for the procurement, MHCP cannot pay for travel expenses of the living donor as these expenses are not allowable costs.

    If the requested care requires prior authorization under Medicaid, prior authorization is required in addition to the EMA CPC approval.

    When the recipient is not approved for transplant
    If, following an evaluation for a kidney transplant, the transplant center indicates that the patient has not been selected to move forward with a kidney transplant, the patient may:

  • • Seek to be listed at another Minnesota kidney transplant center. The pre-kidney transplant evaluation conducted by the initial transplant center, is to be used to evaluate the patient at the second transplant center.
  • • EMA does not provide coverage for a second pre-evaluation.
  • If the patient is approved and listed for transplant at the second transplant center, the kidney transplant pre-evaluation PA will be approved and the claims will be paid once the transplant occurs.

    If the patient does not pursue transplant at another Minnesota kidney transplant center, the PA for the pre-kidney transplant evaluation will be denied.

    If the patient is listed for a kidney transplant and is deceased prior to that kidney transplant occurring, the pre-kidney transplant evaluation will be denied.

    When the recipient decides to not receive kidney transplant
    If the patient is approved for transplant and the organ to transplant is received but not transplanted due to the organ recipient deciding not to move forward, the pre-kidney transplant evaluation PA and transplant PA will be denied.

    Claim processing
    The pre-kidney transplant evaluation PA is approved when the transplant PA is approved within a year of the pre-kidney transplant PA. When the kidney transplant occurs, the transplant center may submit or resubmit the evaluation claims for payment.

    If other medical conditions are discovered during the evaluation for kidney transplant, those conditions must meet the definition of an emergency medical condition to be approved for EMA coverage. Conditions that would not typically meet this definition include, but are not limited to:

  • • Schistosoma - fresh water trematode – flat worm
  • • Strongloides stercoralis - intestinal nematode – round worm
  • • Tuberculosis – refer to the TB program at the Minnesota Department of Health
  • • HIV – refer to the HIV program
  • EMA does not provide coverage for vaccines that are ordered specifically for travel including, but not limited to vaccines for Cholera, Yellow Fever and Typhoid.

    Pre-transplant evaluation includes the following:

  • • Statement of intended transplant procedure: cadaver donor or living donor
  • • Laboratory tests
  • • Screening for infection
  • • Screenings for malignancy
  • • Formal psychosocial evaluation
  • • Cardiovascular evaluation
  • • Pulmonary function
  • • Surgical and pre-anesthesia consultation(s) and evaluation(s)
  • • Donated kidney evaluation
  • • Immunization
  • • Immunosuppressive medication: induction agent, maintenance agent, rejection agent
  • Post-transplant care includes the following:

  • • Immunosuppressive therapy: monitoring, labs, clinical visits, drugs
  • • Monitoring kidney function: labs, clinical visits, tests
  • • Acute rejection: chronic allograft Injury, screening and graft monitoring
  • • Infection and immunization
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