Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-90 - Physician Services › Appendix 144-101-II-90-A

Current through 2024-29, July 17, 2024
90A-01
COVERED ORGAN TRANSPLANT
						PROCEDURES
MaineCare reimburses for services related to organ
						transplants only when all criteria of this section are met, and a
						Department-approved transplant center recommends that the transplant be
						performed. MaineCare does not cover transplants that are considered
						experimental or investigational in nature.
MaineCare covers procedures (evaluations and transplants)
						that include, but are not limited to: heart, heart-lung, bone marrow
						(autologous and allogeneic bone marrow or stem cell transplants), kidney,
						corneal, liver, lung, small intestine, combined liver-small intestine, and
						pancreas transplants.
90A-02
NON-COVERED TRANSPLANT
						SERVICES
MaineCare will not cover evaluations for transplant or
						transplants if any of the following apply:
a. Another procedure of lower cost and of less risk may
						achieve the same or similar result; or
b. The transplant is not expected to make a significant
						difference in the member's health and/or performing the transplant will serve
						primarily an academic purpose; or
c. The transplant is contraindicated by the medical
						condition, age, and prognosis of the member; or
d. The transplant center and/or the member's specialist
						do not recommend that the evaluation for transplant or transplant be
						performed.
90A-03
TRANSPLANTS NOT REQUIRING PRIOR
						AUTHORIZATION
a. In-State Transplant Procedures Not Requiring Prior
						Authorization The following transplant procedures and evaluations do not
						require prior authorization, as long as they are performed in the State of
						Maine:
1)
Kidney Transplants
. Title XVIII of the
Social Security Act
of the Medicare program reimburses for
						kidney transplants for members with end stage renal disease. For members who
						are dually eligible for both Medicare and MaineCare, MaineCare will reimburse
						for only Medicare coinsurance and deductible costs customarily reimbursed by
						MaineCare.
2)
Corneal Transplants
. MaineCare covers
						corneal transplantation to correct corneal opacity or keratoconus.
3)
Autologous or Allogeneic Bone Marrow or Stem
						Cell Transplants
. MaineCare covers bone marrow or stem cell transplants.
						MaineCare covers these procedures when used to replace bone marrow damaged by
						high doses of radiation therapy or chemotherapy.
90A-04
TRANSPLANTS REQUIRING PRIOR
						AUTHORIZATION
All transplants and transplant evaluations performed
						outside the State of Maine require prior authorization, as described in MBM,
						Chapter I. All transplants and transplant evaluations require prior
						authorization unless the transplant meets the criteria of 90A-03 above. Some
						Out of State transplants require additional criteria to be met based on
						industry recognized prior authorization criteria utilized by a national company
						under contract. In cases where the criteria are not met, the Provider/Member
						may submit additional supporting evidence such as medical documentation, to
						demonstrate that the requested service is medically necessary.
This criteria can be found at:
						https://mainecare.maine.gov/ProviderHomePage.aspx
a.
Transplant Procedures Requiring Prior
						Authorization
MaineCare will consider prior authorization for organ
						transplants when all of the following criteria are met:
1) Both the transplant center and the member's in-state
						specialist recommend that the transplant be authorized after the member is
						evaluated; and
2) The transplant meets all other criteria specified in
						Section 90 and this Appendix; and
3) MaineCare has received complete documentation from the
						transplant center to make a determination.
b.
Overview of the Authorization
						Process
The provider must submit complete documentation and all
						criteria listed in this section must be met before MaineCare will consider
						requests for prior authorizations for evaluations and transplant services. In
						making a determination, MaineCare will utilize appropriate staff including but
						not limited to MaineCare Services medical consultants, a medical specialist in
						the relevant field of the requested transplant (e.g., cardiologist for heart
						transplants), a psychiatrist or psychologist and designee(s) of the Director of
						MaineCare Services. MaineCare prior authorization staff will review the
						materials and make a determination by considering established patient selection
						and facility criteria within this section. To make its decision, the Department
						will also look for evidence that the request conforms to general and organ
						specific patient selection criteria, and recommendations of relevant medical
						specialists.
The Department will notify the requesting physician,
						other appropriate providers, and the member of the decision whether an
						evaluation or transplant is prior authorized within thirty (30) days of the
						request. Members may appeal decisions based on information in the
MaineCare Benefits Manual
, Chapter I, "General Administrative
						Policies and Procedures".
1.
Documentation for Prior
						Authorization
The Department will make a decision regarding prior
						authorization for the transplant procedure after reviewing the transplant
						center's report submitted to the MaineCare Prior Authorization Unit. The report
						must include written assessments performed by the appropriate specialists and
						recommendations regarding all possible treatment options. The report must also
						include the specialists' general assessment of the member's anticipated
						prognosis and the risks and benefits (e.g., quality of life) associated with
						each potential treatment option, including transplant.
Providers must clearly document all of the following
						information concerning the member's health in the written report:
i. Diagnosis;
ii. Pertinent medical history;
iii. Alternate treatments performed and their
						results;
iv. Recommended transplant procedure;
v. Expected prognosis after recommended treatment;
vi. Second opinion of the member's condition from a
						board-certified specialist affiliated with a tertiary care hospital. This
						assessment must be based upon a review of the member's medical records and
						previous diagnostic studies and must provide recommendations regarding all
						possible treatment options for the member. Based upon the consultant's
						experience with similar cases, the report must also include the consultant's
						general assessment of the member's prognosis and of the risks and benefits
						(i.e., quality of life) associated with each potential treatment option,
						including transplant; and
vii. A report of an assessment by a mental health
						professional for members age nineteen (19) and older who are being assessed for
						transplants other than a bone marrow transplant. The assessment must address
						the member's mental health and ability to understand both the procedure and its
						psychological aftermath. This report shall include comments on the member's
						ability to take medications and comply with medical recommendations and on the
						member's family or other support system's ability to assist the member in
						coping with both the procedure and its psychological aftermath. The
						professional must state that the member is currently (in the prior six months)
						not abusing drugs or alcohol and has agreed to any on-going counseling
						recommended regarding drug or alcohol abuse.
viii. A written medical record release signed by the
						member or the member's guardian.
MaineCare prior authorization staff may require
						additional information to make a determination.
Providers must submit the request for prior authorization
						for transplant evaluations and transplant. Contact information can be found
						at:
http://www.maine.gov/dhhs/oms/provider_index.html
						.
2.
Duration of Prior Authorization
Any prior authorization for reimbursement for an organ
						transplant procedure shall expire one (1) year after the date of prior
						authorization. If the transplant procedure has not been performed within that
						period, then prior authorization must once again be sought for the
						member.
Providers must repeat the prior authorization process for
						re-authorization. This second review will focus on reassessing the member's
						condition and updating the information submitted for the initial authorization.
						MaineCare will utilize this information to make the appropriate final decision
						regarding re-authorization for an evaluation and approval or denial of coverage
						for the transplant.
3.
Patient Selection Criteria
a.
General Selection Criteria
Members must meet all of the following general criteria
						before MaineCare grants prior authorization of the evaluation and/or the
						transplant:
1. The member's overall physiological condition must
						indicate a reasonable expectation for success; and
2. Alternative medical therapies have been tried and have
						failed or, if tried, would not prevent progressive disability or death; and
3. There is every reasonable expectation that the member
						will strictly adhere to the difficult long-term medical regimen required; and
4. The member is emotionally stable and has a realistic
						attitude toward illness; and
5. Current history (current and for at least 6 months
						preceding the transplant evaluation and actual transplant) is free of alcohol
						or drug abuse ; and
6. There is a reasonable likelihood that the transplant
						will extend the member's life expectancy at least two (2) years and to restore
						a range of physical and social functions of daily living; and
7. The member meets all established criteria and presents
						no contraindications set by the approved transplant center for the specific
						transplant procedure; and
8. The member has been evaluated by a transplant facility
						approved by the Department and the transplant center has recommended the
						transplant and indicated a willingness to perform the procedure.
b.
Specific Selection Criteria
In addition to the general selection criteria stated
						above, each member must meet all transplant center specific criteria for each
						transplant. These criteria are set by the transplant center and include
						indications and contraindications for specific organ transplant procedures
						based on national standards. The Department will not prior authorize any
						transplant if the transplant center does not approve the procedure based on all
						specific selection criteria set by the transplant center.
90A-05
CRITERIA FOR SELECTION OF TRANSPLANT
						CENTERS
MaineCare will only cover transplants performed in
						Department-approved transplant centers.
While physicians may request specific transplant centers,
						the Department reserves the right to select the transplant center a specific
						transplant is approved for. Whenever possible, the Department will approve the
						physician's request for the site of the member's organ transplant evaluation.
						If several Department-approved transplant centers are available for specific
						transplants, the Department reserves the right to authorize the transplant in
						the most cost-effective transplant center. When all other factors are equal,
						the Department will give preference to the provision of services at an in-state
						or regional transplant center in order to enhance continuity of care by
						minimizing the distance that the member and family will have to travel for
						evaluation, the transplant procedure, and after-care.
a.
Initial Approval of Out-of-State Transplant
						Centers (Not required for existing kidney transplant facilities or for any
						corneal or bone marrow transplant facility)
To approve the use of an out-of-state transplant center
						facilities must have the following:
1. Initial approval of an out-of-state transplant center
						requires documentation of a survival rate for the relevant transplant procedure
						comparable with the national experience. This survival rate must be based on a
						sufficient number of procedures (e.g., twelve (12) procedures over the past
						twelve (12) months) to enable the Department to compare the new transplant
						center with other national transplant centers that are performing the
						procedure.
b.
On-going Approval of Out-of-State Transplant
						Centers
The Department will approve out-of-state transplant
						center facilities on a continuing basis using the following criteria:
1. The transplant center has personnel experienced with
						the relevant specialized surgeries, infectious diseases, pediatrics, pathology,
						pharmacology, anesthesiology, tissue typing, immunological and
						immunosuppressive techniques and blood bank support services; and
2. The center has a consistent, equitable, and practical
						protocol for selection of candidates and, at a minimum, must adhere to the
						Department's General Patient Selection Criteria; and
3. The center has adequate services to provide emotional
						and social support for members and their families; and
4. The center has satisfactory arrangements for donor
						procurement services; and
5. The center has demonstrated willingness and the
						ability to provide relevant information to the member's physicians, to
						MaineCare staff, and to other transplantation center personnel; and 6. The
						transplant center maintains all required federal or state accreditations and
						certifications; and 7. The transplant center is a Medicare approved transplant
						center for all applicable transplants, including heart, lung, heart-lung,
						liver, and intestinal transplant centers; and 8. The transplant center
						maintains conformance to the national survival rate criteria as described in
						(a) above; and The transplant center must maintain continuing approval
						dependent upon meeting all above criteria. The transplant center must report
						any changes in status regarding meeting the above criteria to the
						Department.
c.
Initial Approval for In-State Transplant
						Centers
The Department will waive conformance to the national
						survival rate criteria described in (a) above for any new in-state transplant
						centers for a two (2) year period. All other criteria described above must be
						met. This two (2) year start-up period, which will begin with the first
						transplant procedure performed in the in-state facility, is designed to enable
						the in-state transplant center to secure sufficient experience to obtain a
						survival rate that can be compared with national experience.
d.
Continued Approval for In-State Transplant
						Centers
Continued approval for the in-State center after this two
						(2) year start-up period requires evidence of a survival rate that is
						comparable with the national experience and of success with and safety of the
						transplant procedure. The Department must be able to base this survival rate on
						a sufficient number of procedures to enable the Department to compare the
						in-state transplant center with other national transplant centers that are
						performing the procedure. The in-state transplant center must meet all other
						criteria described in (b) above in order to receive continued transplant center
						approval. The transplant center must report any changes in status regarding
						meeting the above criteria to the Department.