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Kidney Transplant Services

Revised: March 14, 2019

Overview

Emergency Medical Assistance provides coverage for kidney transplants to eligible Minnesota Health Care Programs (MHCP) members 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.

Emergency Medical Assistance covers pre-transplant evaluation and care, transplant surgery, and post-transplant related care when all of the following conditions are met:

· Approved through an EMA CPC request

· Transplant inpatient hospital authorization approved

· Meet criteria listed under Transplant Services on the Physician and Professional Services section of the MHCP Provider Manual 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 is certified by United Network for Organ Sharing or Medicare to perform kidney transplants.

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.

EMA CPC Request

When submitting the initial EMA CPC request, providers must include the following:

· Statement of intended kidney transplant for the member

· Provider Information

· Transplant facility or program

· Timeframe for pre-transplant evaluation

· Physician signature on the submitted EMA CPC Request form.

EMA CPC date spans for kidney transplant

· The medical review agent typically approves EMA CPC requests for members awaiting an approved kidney transplant for 12 months. If the member has not received a transplant during that year, a new EMA CPC request would be required and typically approved for an additional 12-month period.

· The medical review agent typically approves EMA CPC requests for the kidney transplant and initial post-transplant period for 12 months.

· Care beyond 12 months post-transplant must be approved through the EMA CPC process

Prior Authorization

If the intent is to perform the kidney transplant in an out-of-state facility, the provider must note this on the inpatient hospital authorization (IHA) for kidney transplant prior authorization (PA). The provider must submit the IHA PA before care is rendered. Refer to the instructions in the MHCP authorization policy for out-of-state services.

If an out-of-state provider performs the surgery to procure the donor kidney at a location outside of Minnesota or its local trade area, the provider must obtain medical prior authorization before the services are provided.

If the requested care requires prior authorization for other services (such as transportation) under Medical Assistance, that prior authorization is required in addition to the EMA CPC approval.

Inpatient Hospital Authorization

The physician must submit the forms for kidney transplant to KEPRO, the authorization medical review agent. See the Inpatient Hospital Authorization (IHA) section of the MHCP Provider Manual.

When submitting the IHA request for kidney transplant, include the following information:

· Transplant facility or program

· Transplant date, if known at that time

· Provider Information

· Diagnosis(es)

The IHA remains in a suspended or non-approved status until the provider notifies KEPRO that the transplant has occurred.

If the member has not received a transplant within a year of the date on the IHA, the provider will complete and submit a new IHA for the following 12-month period.

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

When the patient has received a transplant

The provider is required to contact KEPRO to verify the following information on the IHA for this hospitalization:

· Date of transplant

· Provider

· Admitting diagnosis

KEPRO will then approve the IHA. This approval is required to process the inpatient hospital claim.

Outpatient prescription drugs that do not require a separate authorization

The post-kidney transplant outpatient prescription drugs in the table do not require an authorization once the patient has had an approved kidney transplant. They also do not need to be included on the EMA CPC for these patients. The outpatient prescriptions will be filled in compliance with the standard MHCP drug processes.

Outpatient prescription drugs that are not included in the list continue to require the following:

· An approved EMA CPC Request (DHS-3642)

· A completed outpatient Drug Prior Authorization Form (DHS-4424) (PDF) for each prescription drug.

· Fax to KEPRO or upload on the KEPRO portal, the EMA CPC approval letter and Drug Prior Authorization Form(s) (DHS-4424). Do not send the form to the pharmacy review agent. Requests sent directly to the pharmacy review agent will be returned without review.

Drugs used post kidney-transplant that do not require prior authorization

Drug Name (example)	Generic Name	Strength
ACYCLOVIR	acyclovir	200 MG
ACYCLOVIR	acyclovir	200 MG/5ML
ACYCLOVIR	acyclovir	800 MG
ACYCLOVIR	acyclovir	400 MG
AMOXICILLIN	amoxicillin	250 MG
AMOXICILLIN	amoxicillin	500 MG
AMOXICILLIN	amoxicillin	125 MG
AMOXICILLIN	amoxicillin	250 MG
AMOXICILLIN	amoxicillin	500 MG
ASPIRIN	aspirin	81 MG
ASPIRIN EC	aspirin	81 MG
MEPRON	atovaquone	750 MG/5ML
AZATHIOPRINE	azathioprine	50 MG
AZASAN	azathioprine	75 MG
AZASAN	azathioprine	100 MG
CIPROFLOXACIN HCL	ciprofloxacin HCl	250 MG
CIPROFLOXACIN HCL	ciprofloxacin HCl	500 MG
CIPROFLOXACIN HCL	ciprofloxacin HCl	750 MG
CIPROFLOXACIN HCL	ciprofloxacin HCl	100 MG
CLEOCIN HCL	clindamycin HCl	150 MG
CLEOCIN HCL	clindamycin HCl	300 MG
SANDIMMUNE	cyclosporine	100 MG
SANDIMMUNE	cyclosporine	25 MG
GENGRAF	cyclosporine, modified	100 MG
GENGRAF	cyclosporine, modified	25 MG
CYCLOSPORINE MODIFIED	cyclosporine, modified	50 MG
DAPSONE	dapsone	100 MG
DAPSONE	dapsone	25 MG
FAMOTIDINE	famotidine	20 MG
FAMOTIDINE	famotidine	40 MG
CELLCEPT	mycophenolate mofetil	250 MG
CELLCEPT	mycophenolate mofetil	500 MG
MYFORTIC	mycophenolate sodium	180 MG
MYFORTIC	mycophenolate sodium	360 MG
NYSTATIN	nystatin	100000/ML
OMEPRAZOLE	omeprazole	20 MG
OMEPRAZOLE	omeprazole	10 MG
OMEPRAZOLE	omeprazole	40 MG
PROTONIX	pantoprazole sodium	40 MG
PROTONIX	pantoprazole sodium	20 MG
PREDNISONE	prednisone	1 MG
PREDNISONE	prednisone	10 MG
PREDNISONE	prednisone	2.5 MG
PREDNISONE	prednisone	20 MG
PREDNISONE	prednisone	5 MG
PREDNISONE	prednisone	50 MG
RANITIDINE HCL	ranitidine HCl	150 MG
RANITIDINE HCL	ranitidine HCl	300 MG
RANITIDINE HCL	ranitidine HCl	150 MG
RANITIDINE HCL	ranitidine HCl	300 MG
TACROLIMUS	tacrolimus	1 MG
TACROLIMUS	tacrolimus	5 MG
TACROLIMUS	tacrolimus	0.5 MG
VALCYTE	valganciclovir HCl	450 MG
VALCYTE	valganciclovir HCl	50 MG/ML
BACTRIM	sulfamethoxazole/trimethoprim	400MG-80MG
BACTRIM DS	sulfamethoxazole/trimethoprim	800MG/160MG

Physician-administered drugs authorization process

For physician-administered injection authorization (J Code drugs), complete the MHCP Authorization Form (DHS-4695) (PDF) for each requested drug. Fax this form and the EMA CPC approval letter to the pharmacy review agent for review. Refer to the Drug Authorization section of the MHCP Provider Manual for more details.

Noncovered Services

Noncovered vaccines:
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.

Noncovered procedure:
Pre-emptive kidney transplants are not covered under EMA.

Billing

Living donor

In cases where the kidney is acquired from a living donor, the charges are billed under the EMA member’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 after the transplant has occurred

· Complications that arise after the date of the donor’s discharge are billed under the member’s health insurance number, this includes facility and physician service charges

· Claims up to six months post-donation of organ are billed using the member’s health insurance claim number

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

Member 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 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 MHCP will pay the claims after the transplant occurs.

If the patient does not pursue a transplant at another Minnesota kidney transplant center, the claims for the pre-transplant evaluation are denied.

If the patient is listed for a kidney transplant and is deceased prior to that kidney transplant occurring, kidney transplant evaluation claims are denied.

Member decides not to receive kidney transplant

If the patient is approved for a transplant and the organ to transplant is received but not transplanted due to the member deciding not to move forward, the transplant IHA is denied.