1. (a) Organ transplantations are covered under the Medicaid program if they are of demonstrated therapeutic value, medically necessary and medically appropriate, and likely to result in the prolongation and the improvement in the quality of life of the applicant.

2. (b) The following organ transplantations have been deemed to satisfy the criteria of subsection (a) of section 17-134d-43, in all cases, and the costs associated with such procedures will be covered under Medicaid without the necessity of the patient obtaining prior authorization from the Department:

   1. (1) bone;
   2. (2) bone marrow;
   3. (3) kidney;
   4. (4) cornea.
3. (c) Except as provided in subsection (b) of section 17-134d-43, prior authorization must be obtained from the Department before the costs associated with an organ transplantation will be covered under Medicaid.
4. (d) The final decision as to whether authorization will be granted for a patient to incur Medicaid covered costs associated with an organ transplantation is made by the Department on a case-by-case basis. No such authorization will be granted unless the Department is fully satisfied that the conditions of subsection (a) of section 17-134d-43 have been met.
5. (e) In order to assist the Department in determining whether a request for prior authorization satisfies the criteria of subsection (a) of section 17-134d-43, there has been established a Transplant Advisory Committee of the Department of Income Maintenance. The members of the committee are appointed by the Commissioner, provide the Department with technical assistance and expertise in the field of organ transplantation, and are drawn from the medical health and insurance communities.
6. (f) The Transplant Advisory committee has developed, and continues to review and modify, specific medical criteria as they relate to particular organ transplantation procedures. In addition, the committee may provide technical assistance to the Department in reviewing a particular prior authorization request. In no event, however, are the criteria (guidelines) or recommendations of the committee binding on the Department. A final decision that a prior authorization request fails to satisfy the provisions of subsection (a) of section 17-134d-43 would not be rendered without considering the medical opinion of a qualified organ transplantation expert(s) in the community.
7. (g) The medical criteria developed by the Transplantation Advisory Committee, and any amendments thereto, are on file in the Department and available to all interested parties. The advisory nature of any such criteria, to assist the Department in determining whether the subsection (a) of section 17-134d-43 prior authorization standards have been satisfied, is emphasized.

(Effective May 1, 1987)