(1) This rule provides the requirements for medicaid coverage of organ transplantations. The requirements in this rule are in addition to those contained in ARM 37.85.401, 37.85.402, 37.85.406, 37.85.407, 37.85.410, 37.85.414 and 37.85.415.

(2) General requirements for medicaid coverage of transplantations are as follows:

(a) The transplantation must be medically necessary.

(b) Prior authorization for referral to an out-of-state facility for an evaluation and organ transplantation must be obtained from the department or its designated review organization.

(c) The transplant candidate must meet the patient selection criteria set forth by the department's designated review organization.

(d) The medicaid program covers only the following organ transplantation services for persons over the age of 21, subject to the provisions of (2) (e) :

(i) allogenic and autologous bone marrow;

(ii) kidney, inclusive of thoracic duct drainage and dental exam;

(iii) cornea;

(iv) lymphocyte immune globulin preparation.

(e) For purposes of establishing organ transplant requirements and to more specifically defining coverage or non-coverage of various types of organ transplantations, the department hereby adopts and incorporates by reference the following sections of the Medicare Coverage Issues Manual (HCFA-Pub. 6) published by the health care financing administration of the United States department of health and human services. A copy of the incorporated sections of the Medicare Coverage Issues Manual (HCFA-Pub. 6) may be obtained from the Department of Public Health and Human Services, Health Policy and Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951. The incorporated sections are as follows:

(i) HCFA-Pub. 6, section 35-30, as amended through March 1992, pertaining to allogenic and autologous bone marrow transplantation;

(ii) HCFA-Pub. 6, section 35-50, as amended through September 1991, pertaining to non-coverage of the medical procedure cochleostomy with neurovascular transplant for treatment of meniere's disease;

(iii) HCFA-Pub 6, section 35-53.1, as amended September 1991, pertaining to pediatric liver transplantation;

(iv) HCFA-Pub. 6, section 35-58, as amended through April 1983, pertaining to thoracic duct drainage (TDD) as a covered service when furnished to a kidney transplant recipient or individual approved to receive a transplant;

(v) HCFA-Pub. 6, section 35-82, as amended through January 1988, pertaining to non-coverage of pancreas transplantation;

(vi) HCFA-Pub. 6, section 35-87, as amended through May 1989, pertaining to heart transplants;

(vii) HCFA-Pub. 6, section 45-22, as amended through June 1988, pertaining to FDA approval and use of lymphocyte immune globulin preparations;

(viii) HCFA-Pub. 6, section 50-23, as amended through July 1990, pertaining to the safe and effective use of histocompatibility testing procedures; and

(ix) HCFA-Pub. 6, section 50-26, as amended through May 1989, pertaining to dental exam as part of a comprehensive workup prior to a renal transplant surgery.

(3) The medicaid program covers organ transplantation services for persons 21 years of age or less as determined medically necessary, subject to the provisions of ARM 37.86.4701 and (2) (a) through (2) (e) of this rule.