1. (1) The Health Systems Division (Division) shall make payment for transplant services identified in these rules as covered for eligible Medicaid clients defined in OAR 410-124-0010 that meet the transplant criteria outlined in OAR 410-124-0000 through 410-124-0040 and the Prioritized List of Health Services guideline notes.

2. (2) The Division shall reimburse for transplants if:

   1. (a) All Division criteria are met; and
   2. (b) Transplants are medically necessary and meet the requirements for physician and hospital services; and
   3. (c) The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services adopted under OAR 410-141-3830.

3. (3) The following transplants are covered by the Division if the criteria in (2) above is met:

   1. (a) Solid organ, heart, kidney, liver, lung, heart-lung, pancreas, kidney-pancreas, and small bowel;
   2. (b) Bone marrow and peripheral stem cell;
   3. (c) Corneal transplants;
   4. (d) Simultaneous multiple organ transplants are covered only if specifically identified as paired on the same currently funded line on the Oregon Health Plan (OHP) Prioritized List of Health Services whether the transplants are for the same underlying disease or for unrelated, but concomitant, underlying diseases.

4. (4) Not Covered Transplant Services: The following types of transplants are not covered by the Division:

   1. (a) Transplants which are considered experimental or investigational or which are performed on an experimental or investigational basis, as determined by the Division;
   2. (b) Second bone marrow transplants are not covered except for tandem autologous transplants for multiple myeloma.
   3. (c) Transplants which are not described as covered in OAR 410-141-3830.

Statutory/Other Authority

ORS 413.042

Statutes/Other Implemented

ORS 414.065

History

DMAP 49-2023, amend filed 06/30/2023, effective 07/01/2023
DMAP 2-2023, temporary amend filed 01/31/2023, effective 02/01/2023 through 07/30/2023
DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
OMAP 95-2004(Temp), f. & cert. ef, 12-30-04 thru 3-15-05
OMAP 92-2004(Temp), f.& cert. ef. 12-10-04 thru 3-15-05
OMAP 68-2004(Temp), f. 9-14-04, cert. ef. 10-1-04 thru 3-15-05
OMAP 1-2003, f. 1-31-03, cert. ef. 2-1-03
OMAP 34-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 21-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 18-2000, f. 9-28-00, cert. ef. 10-1-00
HR 17-1997, f. & cert. ef. 7-11-97
HR 19-1995, f. 9-28-95, cert. ef. 10-1-95
HR 4-1994, f. & cert. ef. 2-1-94
HR 17-1992, f. & cert. ef. 7-1-92
HR 37-1990, f. 11-6-90, cert. ef. 11-9-90
HR 22-1990, f. & cert. ef. 7-17-90
HR 8-1990(Temp), f. 3-30-90, cert. ef. 4-1-90