Prior Authorization Request Services and Forms

Transplants: Heart, Liver, Stem Cell

Heart Transplant

An individual may be eligible for a heart transplant if the individual meets the following criteria and written prior authorization has been obtained from the South Dakota Medical Assistance program:

1. The individual must have a critical medical need with a life expectancy of less than one year without a transplant;
   
2. The individual must have tried or considered all other medical and surgical therapies that might be expected to yield both short‑ and long‑term survival;
   
3. The individual must be free of all strongly adverse factors, such as severe pulmonary hypertension; renal or hepatic dysfunction not explained by the underlying heart failure and not considered reversible; acute severe hemodynamic compromise at the time of transplantation if accompanied by compromise or failure of one or more vital end‑organs; symptomatic peripheral vascular or cerebrovascular disease; chronic obstructive pulmonary disease or chronic bronchitis; active systemic infection; recent and unresolved pulmonary infarction, pulmonary roentgenographic evidence of infection or abnormalities of unclear etiology; uncontrolled systemic hypertension, either at transplantation or prior to development of end‑stage heart disease; cachexia, even in the absence of major end‑organ failure; a history of a behavior pattern considered likely to interfere significantly with compliance with a disciplined medical regimen; or any other systemic disease considered likely to limit or preclude survival and rehabilitation after transplantation;
   
4. The individual must be free of other factors less adverse but considered importantly adverse such as insulin‑requiring diabetes mellitus with associated vascular complications of kidney or retina, severe neuropathy; or asymptomatic severe peripheral or cerebrovascular disease;
   
5. The plans for long‑term adherence to a disciplined medical regimen must be feasible and realistic for the individual patient; and
   
6. The procedure will be performed at a Medicare-approved transplant center.

Liver Transplant

An individual may be eligible for a liver transplant if the individual meets the following criteria and written prior authorization has been obtained from the South Dakota Medical Assistance program:

1. The individual must have a critical medical need with less than 24 months of expected survival;
2. The individual must be free of all strongly adverse factors such as irreversible brain damage; multi-system failure not correctable by transplant; malignancy outside of the liver (excluding skin cancer); alcohol or other substance abuse not in remission for at least 6 months; advanced cardiopulmonary disease; active systemic infection; other significant co-morbidities;  or history of a  behavior pattern considered likely to interfere significantly with compliance to a disciplined medical regimen;
3. The plans for long-term adherence to a disciplined medical regimen must be feasible and realistic for the individual patient; and
4. The procedure will be performed at a Medicare-approved transplant center.

Stem Cell Transplant -- not available at this time

CHAPTER 67:16:31: ORGAN TRANSPLANTS

• 67:16:31:01 Definitions.
• 67:16:31:02 Organ transplants covered.
• 67:16:31:02.01 Liver transplants limited to certain centers.
• 67:16:31:03 Conditions for covered heart transplants.
• 67:16:31:04 Heart transplants limited to certain centers.
• 67:16:31:05 Individuals eligible for Medicare must apply to Medicare.
• 67:16:31:06 Transplants limited to human organs.

Documentation Requirements for Prior Authorization Requests:

• Prior Authorization Request Form

Fax or Mail completed form and documentation to:

• Department of Social Services
  Division of Medical Services
  811 E 10th Street, Dept. 8
  Sioux Falls, SD 57105
  
• Phone: -605-367-7601
  
• Fax: 605-367-5253