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Multi Visceral Transplant Policy For Adults

Multi Visceral Transplant Policy For Adults

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Published by Ann Weiler
Multi Visceral Transplant Policy For Adults
Multi Visceral Transplant Policy For Adults

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Published by: Ann Weiler on Jun 28, 2013
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07/02/2013

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Illinois Medicaid Policy on Multi-Visceral Transplants for Adults, 6/27/13Page
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Pat Quinn, Governor Julie Hamos, Director 
201 South Grand Avenue East
Telephone:
(217) 782-1200Springfield, Illinois 62763-0002
TTY
: (800) 526-5812
ILLINOIS MEDICAID POLICYON MULTI-VISCERAL TRANSPLANTS FOR ADULTS
ILLINOIS MEDICAID POLICY
Illinois Medicaid will not authorize coverage of Multi-Visceral Transplant (MVT) procedures for adults atthis time. There is no peer-reviewed and published literature that demonstrates the effectiveness andsafety of this procedure and, thus, it is experimental in nature. The policy will not be re-examined basedon the specific circumstances of individual Medicaid clients.
BASIS OF ILLINOIS MEDICAID POLICY
This policy is based upon the unanimous recommendation of the Ad Hoc Professional Ethics AdvisoryCommittee which met on May 17, 2013. The committee met for the purpose of assisting the IllinoisDepartment of Healthcare and Family Services (HFS) in establishing a Medicaid policy for coverage of MVT for adults.
AD HOC PROFESSIONAL ETHICS ADVISORY COMMITTEE
 
BACKGROUND
On February 22, 2013, HFS received an informal request followed up with a formal request on March 7,2013 from the Indiana University (IU) Transplant Surgery Team to prior-authorize the performance of MVT for two adult Medicaid clients. IU indicated that it would be submitting more prior authorizationrequests for the performance of MVT for adults.Although Illinois administrative rule authorizes MVT for children, it is silent on coverage of MVT foradults. Illinois Medicaid has not previously authorized and does not have written standards forapproving MVT for adults. The Illinois State Medicaid Plan states that a transplant procedure will not beapproved if the procedure is experimental, another procedure costing less or of less risk will achieve the
same results, the transplant does not make a difference in the patient’s health and performing the
transplant will merely serve an academic purpose, or the transplant is relatively unsafe given the ageand prognosis of the individual.Illinois administrative rule requires hospitals performing transplants to be certified by HFS. Neither IUnor any other hospital is certified by HFS to perform MVT for adults. Illinois administrative ruleestablishes an exceptions process to the formal certification process.
PURPOSE AND COMPOSITION OF AD HOC PROFESSIONAL ETHICS ADVISORY COMMITTEE
The Ad Hoc Professional Ethics Advisory Committee (Committee) met:
• To
assist HFS regarding whether a policy should be adopted to approve MVT for adults.
 
Illinois Medicaid Policy on Multi-Visceral Transplants for Adults, 6/27/13Page
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If HFS adopted such a policy, to assist HFS in the establishment of written standards to ensurecompliance with state and federal laws and regulations.The Committee was comprised of six members. The Committee members were requested to servebased on their qualifications, expertise, diversity, professional standing, record of service andleadership. The Committee members volunteered their services and received no compensation. Theirbackgrounds are:
PhD-Vice President of Ethics at a hospital system;
JD, LLM-Clinical Ethicist and Assistant Director of Ethics at a hospital system;
MD (Internal Medicine and Cardiology) with highly responsible federal government experience;
MD, MHA (Cardio Vascular Surgeon), Ethics Consultant, past president of a medical association;
PhD, MSW, section chief of a state agency; and
MD, senior director of community based practice at a large academic hospital system
MEETING AND RECOMMENDATION OF AD HOC PROFESSIONAL ETHICS ADVISORY COMMITTEE
 The Committee met on May 17, 2013. In addition to the Committee members, present were DirectorJulie Hamos, Dr. Arvind Goyal, HFS Medical Director, and Jeanette Badrov, HFS General Counsel. Aftercareful consideration, the Committee made a unanimous recommendation to HFS that:As there is no peer-reviewed and published literature which demonstrates the effectiveness andsafety of the MVT procedure and, thus, it is experimental in nature, Illinois Medicaid should notapprove requests for coverage of MVT for adult patients at this time. The policy should not bebased on the specific circumstances of individual Medicaid clients.
BASIS OF RECOMMENDATION OF AD HOC PROFESSIONAL ETHICS ADVISORY COMMITTEE
 The following information was presented to the Committee:
Prior to the meeting, Dr. Goyal conducted a methodical and time intensive review which heshared with the Committee. Dr. Goyal consulted with two IU transplant surgeons and their lobbyist
on the patients’ medical situations, rev
iewed their medical records including referral requests andtest data, and reviewed the limited literature related to MVT. Dr. Goyal consulted with twotransplant centers in Chicago, neither of which performed or offered MVT. Dr. Goyal engaged IU tounderstand their protocols, basis for their MVT recommendation, cost structure, volume of theircases (38 in 4 years) and patient outcomes data. Dr. Goyal analyzed existing policy and relevantHFS claims data internally. Dr. Goyal studied, and in some cases held phone conferences, to learncoverage policies of Medicare, several other state Medicaid programs, and multiple private payers.
Dr. Goyal investigated and verified that IU is on the list of Transplant Programs approved byMedicare to perform MVT procedures for adults with certain diagnoses. However, Medicare doesnot pay for MVTs for patients with diagnoses similar to one of the patients (who is covered underMedicare), as Dr. Goyal verified that IU had made no request to Medicare to cover the MVTprocedure. Dr. Goyal confirmed that Illinois Medicaid has not certified IU to perform MVT foradults. Dr. Goyal also verified the credentials of the four transplant surgeons on the IU operatingteam.
• T
he Committee reviewed the two IU prior authorization requests containing patient specificinformation, a written request from IU on behalf of each patient, and a summary of pertinent partsof federal and state regulations and the Illinois State Medicaid Plan.

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