Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 174 - HEALTH CARE ADMINISTRATIVE RULES (HCAR) › Chapter 011 - TRANSPLANTATION SERVICES › Section 13 174 011 - TRANSPLANTATION SERVICES

Current through June, 2024
4.228 Transplantation Services.
(5/1/2023, GCR 22-099)
4.228.1 Definitions
For the purposes of this rule, the term:
"Transplantation services" means a medical procedure
				  performed to replace a diseased or damaged body part with a healthy
				  one.
4.228.2 Covered
				Services
Vermont Medicaid covers medically necessary transplantation
				  services for the beneficiary including harvesting, preservation, and
				  transportation of cadaver organs. Vermont Medicaid also covers, under the
				  Medicaid of the person receiving the transplantation, medically necessary
				  transplantation services for live donors, including post transplantation
				  services and transportation.
4.228.3 Qualified Providers
Providers must be working within the scope of their practice
				  and enrolled in Vermont Medicaid. Providers must also be certified by the
				  American Society of Transplant Surgeons (ASTS) and maintain their membership in
				  good standing and experienced in postoperative care and management of an
				  immunosuppressive regimen.
4.228.4 Qualified Facilities
The transplant facility must meet the following
				  criteria:
(a) Be fully accredited as a
				transplant center by applicable state and federal agencies.
(b) Be in compliance with all applicable
				state and federal laws which apply to organ acquisition and transplantation
				including equal access and non-discrimination laws.
(c) Have an interdisciplinary team to
				determine the suitability of candidates for transplantation on an equitable
				basis.
(d) At the time Medicaid
				coverage is requested, the center must provide current documentation that it
				provides high quality care relative to other transplant centers.
(e) Provides all medically necessary services
				required including management of complications of the transplantation and late
				infection and rejection episodes. Failure of the transplant is considered a
				complication and re-transplantation must be available at the center.
4.228.5 Conditions for Coverage
The Medicaid beneficiary must meet the following
				  conditions:
(a) The Medicaid
				beneficiary has a condition for which transplantation is the appropriate
				treatment.
(b) All other medically
				feasible forms of medical or surgical treatment have been considered, and the
				most effective and appropriate medically indicated alternative for the
				beneficiary is transplantation services.
(c) The Medicaid beneficiary meets all
				medical criteria for the proposed type of transplantation based upon the
				prevailing standards and current practices. These would include, but are not
				limited to:
(1) Test lab results within
				identified limits to assure successful transplantation and recovery.
(2) Diagnostic evaluations of the
				beneficiary's medical and mental health that indicate there will be no
				significant adverse effect upon the outcome of the transplantation.
(3) Assessment of other relevant factors that
				might affect the clinical outcome or adherence to an immunosuppressive regimen
				and rehabilitation program following the transplant.
(4) The beneficiary or an individual
				authorized to make health care decisions on the beneficiary's behalf has been
				fully informed of the risks and benefits of the proposed transplant including
				the risks of complications, continuing care requirements, and the expected
				quality of life after the procedure.
4.228.5 Prior Authorization
The Vermont Medicaid fee schedule contains a detailed list of
				  covered services and indicates which services require prior authorization. The
				  fee schedule can be found on the Department of Vermont Health Access
				  website.
4.228.6 Non-Covered
				Services
Transplantation services are not covered if the procedure is
				  experimental or investigational.