Transplant Service Documentation Requirements

This policy specifies documentation requirements for pre‑transplant diagnostic tests, evaluations, consultations, and listing requests for solid organ and stem cell/bone marrow transplants (e.g., kidney, liver, heart, lung, pancreas, intestine), requiring organ‑specific data such as MELD/INR for liver, GFR for kidney, RHC/peak VO2 for heart, and PFTs/6‑minute walk for lung; corneal, pancreatic islet auto‑transplant and parathyroid auto‑transplant require a separate Health Plan prior authorization form and are not covered by these documentation criteria. Requests require prior authorization with time‑limited approvals (evaluation auths valid 6 months, listing auths 12 months), mandatory psychosocial and dental clearances, adherence to specified lab/imaging/test timing and exclusions, and separate authorization for transplant admissions or other non‑follow‑up services.

"Pre-transplant diagnostic tests and consultations performed by a provider that are necessary to assess and evaluate transplant candidacy for acceptance into a transplant program."