Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.16 - Bone Marrow Transplant

Current through June 25, 2024
A. Medicaid covers
				bone marrow transplants as noted below and does not require prior authorization
				for medical necessity from the UM/QIO.
B. Bone marrow transplants (BMT), Autologous,
				Syngeneic, or Allogeneic, are covered for inpatient and outpatient when the
				following criteria are met:
1. Candidate is
				less than fifty-six (56) years of age for allogeneic, < sixty-six (66) if
				fully matched sibling donor.
2.
				Candidate is less than seventy (70) years of age for autologous.
3. Karnofsky >70 or ECOG <3.
4. Allogeneic HLA-MLC match, 1 antigen
				mismatch accepted.
5. Infections
				controlled for forty-eight (48) hours prior to transplant.
6. Left ventricular ejection fraction
				>40%.
7. FEV1 of >50% of
				predicted.
8. Dlco >60% of
				predicted.
9. All other treatments
				have been attempted or considered and none will prevent progressive disability
				and/or death.
10. The candidate
				and/or legal representative understands the transplant risks and benefits,
				gives informed consent, and has the capacity and is willing to comply with
				needed care, including immunosuppressive therapy.
11. The candidate has been approved by the
				transplant review team.
12. The
				candidate's immunization history and HIV status has been obtained.
13. A psychosocial evaluation has been
				performed for the adult candidate or, if the candidate is a child, for the
				family, with the following results:
a)
				Candidate's psychiatric disorders, if present, are being treated.
b) Candidate's social support system has been
				evaluated and found to be adequate.
c) Candidate has no previous history of
				significant non-compliance to medical treatment.
14. Specific Diagnostic Inclusion Criteria
				(Allogeneic BMT or PSCT)
a) Severe aplastic
				anemia.
b) Pure erythrocyte
				aplasia.
c)
				Myelodysplasia.
d) Severe
				hemoglobinopathy, including sickle cell, thalassemia.
e) Selected immunodeficiency syndrome
				including SCID, Wiskott-Aldrich, Chediak-Higashi
f) Genetic storage disease, including
				Hurler's, Morquio's.
g) Primary
				amyloidosis.
h) Paroxysmal
				nocturnal hemoglobinuria.
i) Severe
				platelet dysplasia.
j) Acute
				lymphocytic leukemia, in first remission if high risk, at early relapse, or in
				second remission.
k) Acute
				myelogenous leukemia, in same clinical states as listed for acute lymphocytic
				leukemia.
l) Chronic lymphocytic
				leukemia.
m) Chronic myelogenous
				leukemia.
n) Hodgkin's lymphoma,
				failed first line therapy or failed at least one standard chemotherapy
				regimen.
o) Non-Hodgkin's lymphoma
				failed or responsive to first line therapy or high risk during first
				remission.
p) Familial
				hemophagocytic lymphohistiocytosis (FHL) also known as familial
				erythrophagocytic.
q)
				Lymphohistiocytosis (FEL).
15. Specific Diagnostic Inclusion Criteria
				(Autologous BMT or PSCT)
a) Acute lymphocytic
				leukemia in first remission if high risk, at early relapse, or in second
				remission.
b) Acute myelogenous
				leukemia in same clinical states as listed for acute lymphocytic
				leukemia.
c) Chronic lymphocytic
				leukemia.
d) Chronic myelogenous
				leukemia.
e) Hodgkin's lymphoma,
				for failed first line therapy or if failed at least one standard chemotherapy
				regimen.
f) Multiple Myeloma-a
				single autologous BMT/SCT transplant will be considered for beneficiaries with
				Durie-Salmon stage II or stage III disease if the following criteria is met.
				Newly diagnosed disease or responsive multiple myeloma. This includes
				beneficiaries with previously untreated disease, those with at least a partial
				response to prior chemotherapy, which is defined as 50% decrease in either
				measurable serum and/or urine paraprotein or in bone marrow infiltration,
				sustained for at least one (1) month, and those in responsive relapse with
				adequate renal, pulmonary, and hepatic function.
16. Tandem BMT/SCT for multiple myeloma is
				specifically excluded from coverage.
a)
				Non-Hodgkin's lymphoma, either failed or responsive to first line therapy or,
				if high risk, during first remission
b) Neuroblastoma.
c) Nephroblastoma.
17. Transplant facilities must meet Medicaid
				facility criteria.