(a) Subject to the specifications, conditions, and limitations
established by the department, organ transplant services are covered as follows:
(1) Coverage is limited to those services, as approved by the
department or its designee, that are determined to be reasonable, medically
necessary, and standard medical procedures.
(2) Coverage includes solid and nonsolid organ procurement
(including acquiring/harvesting, processing, preserving, storing, distributing,
and tissue typing). If a hospital obtains an organ outside of the hospital,
the hospital must obtain it from an organ procurement organization designated
by the secretary of the Department of Health and Human Services. Coverage
does not include donor expenses.
(3) Coverage of each type of solid organ transplants is limited
to an initial transplant and one subsequent retransplant because of rejection
as a lifetime benefit.
(b) As specified by the department or its designee, prior authorization
is required for certain organ transplant services. If a covered organ transplant
has been prior authorized as medically necessary by the department or its
designee because of an emergent, life-threatening situation, a maximum of
30 days of inpatient hospital services during a Title XIX spell of illness
may be covered beginning with the actual first day of the transplant. This
coverage is in addition to covered inpatient hospital days provided before
the actual first day of the transplant. This 30-day period is considered
a separate inpatient hospital admission for reimbursement purposes. Physician
services that the department or its designee determines to be reasonable and
medically necessary are also covered during the 30-day period.
(c) If expenditures for a single inpatient hospital admission
exceed the $200, 000 limit on hospitalization-related services specified in §29.1112
of this title (relating to Exclusions and Limitations), expenditures for that
admission are excluded in calculating expenditures toward the limit. This
policy only applies to an inpatient hospital admission to perform a covered
organ transplant procedure determined to be medically necessary because of
an emergent, life-threatening situation.
(d) To be reimbursed for transplant services, a hospital must
meet the requirements included in the Social Security Act, §1138 and
be approved and designated by the department as an organ transplant facility.
(e) For purposes of this section, the term ~organ~ means a
human heart, kidney, liver, cornea, or bone marrow, and any other human organ
or tissue specified by the department.
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Source Note: The provisions of this §354.1175 adopted to be effective September 1, 1987, 12 TexReg 2579; amended to be effective April 13, 1988, 13 TexReg 1392; amended to be effective January 4, 1989, 13 TexReg 6292; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective November 28, 1996, 21 TexReg 11287; amended to be effective January 1, 1999, 23 TexReg 13076; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561 |