(1) The department pays for medically necessary transplant procedures only for eligible medical assistance clients who are not otherwise subject to a managed care organization (MCO) plan. Clients eligible under the alien emergency medical (AEM) program are not eligible for transplant coverage.
(2) The department covers the following transplant procedures when the transplant procedures are performed in a hospital designated by the department as a "center of excellence" for transplant procedures and meet that hospital's criteria for establishing appropriateness and the medical necessity of the procedures:
(a) Solid organs involving the heart, kidney, liver, lung, heart-lung, pancreas, kidney-pancreas and small bowel;
(b) Bone marrow and peripheral stem cell (PSC);
(c) Skin grafts; and
(d) Corneal transplants.
(3) For procedures covered under subsections (2)(a) and (b) of this section, the department pays facility charges only to those hospitals that meet the standards and conditions:
(a) Established by the department; and
(4) The department pays for skin grafts and corneal transplants to any qualified hospital, subject to the limitations in this chapter.
(5) The department deems organ procurement fees as being included in the payment to the transplant hospital. The department may make an exception to this policy and pay these fees separately to a transplant hospital when an eligible medical medical client is covered by a third-party payer which will pay for the organ transplant procedure itself but not for the organ procurement.
(6) The department, without requiring prior authorization, pays for up to fifteen matched donor searches per client approved for a bone marrow transplant. The department requires prior authorization for matched donor searches in excess of fifteen per bone marrow transplant client.
(7) The department does not pay for experimental transplant procedures. In addition, the department considers as experimental those services including, but not limited to, the following:
(a) Transplants of three or more different organs during the same hospital stay;
(b) Solid organ and bone marrow transplants from animals to humans; and
(c) Transplant procedures used in treating certain medical conditions for which use of the procedure has not been generally accepted by the medical community or for which its efficacy has not been documented in peer-reviewed medical publications.
(8) The department pays for a solid organ transplant procedure only once per client's lifetime, except in cases of organ rejection by the client's immune system during the original hospital stay.
(9) The department pays for bone marrow, PSC, skin grafts and corneal transplants when medically necessary.
(10) The department may conduct a post-payment retrospective utilization review as described in WAC 388-550-1700
, and may adjust the payment if the department determines the criteria in this section are not met.
[WSR 11-14-075, recodified as § 182-550-1900, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
, 74.09.500. WSR 07-14-018, § 388-550-1900, filed 6/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090
, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-1900, filed 12/18/97, effective 1/18/98.]