Solid Organ Transplants /
Fax or email this completed form
and other required documentation including letter of
medical necessity from physician, patient history of illness,
all pertinent laboratory findings, diagnostic testing including radiology reports, and other pertinent documentation / / Fax: (904) 357-6331
Email:
Phone: 1 (800) 955-5692 Extension: 19001
Section A
Physician Information/Requesting Provider
/Name:
/BCBSF No:
/National Provider Identifier (NPI):
Contact Name:
/Phone:
Facility Information/Location where services will be rendered /
Name:
/BCBSF No:
/National Provider Identifier (NPI):
Contact Name:
/Phone:
Transplant Coordinator /Name:
/Phone:
/Fax:
Financial Coordinator /Name:
/Phone:
/Fax:
Member Information / Last Name: / First Name: / Male FemaleMember/Contract Number (alpha and numeric): / Date of Birth:
Procedure Information / Procedure Code(s): / Procedure Description:
Diagnosis code(s): / Diagnosis Description:
Date of Service/Tentative Date:
Member Status / This is an urgent request / Member is currently in-member
Coding / ICD-9 codes:
Diagnosis codes description (Including co-morbidities):
Section B – General Information
Check all boxes and complete all entries that apply:
What type of end-stage organ disease does the member have? Check all the apply:Heart / Pancreas / Multiple Visceral (specify organs)
Heart/Lung / Kidney / Small Bowel
Lung / Liver / Pancreatic Islet Cell
The member will receive:
Living organ / Cadaveric organ
Section C – Current Medical Information
Check all boxes and complete all entries that apply:
Yes / No / Does the member have any psychosocial conditions or chemical dependency affecting ability to adhere to therapy?Yes / No / Is the member actively involved in alcohol or drug abuse treatment?
If Yes,
- provide date treatment began:
- Attachacopy of the most recent drug screen including date collected.
Yes / No / Does the member have an untreated systemic infection making immunosuppression unsafe, including chronic infection?
Yes / No / Does the member have systemic disease that could be exacerbated by immunosuppression?
Yes / No / Does the member have any serious health conditions that create an inability to tolerate surgery or post-transplant care?
Yes / No / Does the member have an untreatable end-stage disease of another organ?
If Yes, explain:
Yes / No / Does member have adequate support system in place?
Yes / No / Does the member have a known, current malignancy?If Yes, attach documentation of type, location, and treatment.
Yes / No / Does the member have a recent malignancy with a high rate of recurrence?
Yes / No / Has the entire transplant evaluation workup been completed?
Section D – Organ Specific Information
Check all boxes and complete all entries that apply:
Heart - AdultWhich of the following indications is applicable for the member?
Heart failure with evidence of maximal VO2 <10 ml/kg/min with achievement of anaerobic metabolism
Heart failure with evidence of refractory cardiogenic shock
Heart failure with evidence of documented dependence on intravenous inotropic support to maintain adequate organ perfusion
Recurrent unstable ischemia not amenable to bypass surgery or angioplasty
Maximal VO2<14 ml/kg/min and major limitation of the member’s activities
Recurrent symptomatic ventricular arrhythmias refractory to ALL accepted therapeutic modalities
Instability of fluid balance/renal function not due to member non-compliance with regimen of weight monitoring, flexible use of diuretic drugs and salt restriction
Severe ischemia consistently limiting routine activity not amenable to bypass surgery or angioplasty
Heart–Pediatric
Which of the following indications is applicable for the member?
Heart failure with persistent symptoms at rest thatrequires continuous infusion of intravenous inotropic agents.
Heart failure with persistent symptoms at rest that requires mechanical circulatory or ventilator support.
Severe limitation of exercise and activity (if measurable, such members would have a peak maximum oxygen consumption <50% predicted for age and sex.)
Cardiomyopathies or previously repaired or palliated congenital heart disease and significant growth failure attributable to the heart disease.
Near sudden death and/or life-threatening arrhythmias untreatable with medications or an implantable defibrillator.
Restrictive cardiomyopathy with reactive pulmonary hypertension.
Reactive pulmonary hypertension and potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotropic heart transplantation in the future.
Anatomical and physiological conditions likely to worsen the natural history of congenital heart disease in infants with a functional single ventricle.
Anatomical and physiological conditions that may lead to consideration for heart transplantation without systemic ventricular dysfunction.
Intestinal/Multivisceral
Yes / No / Is the member TPN dependent?
If Yes, for how long?
Yes / No / Does the member have intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance)?
Yes / No / Does the member have evidence of impending end-stage liver failure?
If Yes, explain:
Yes / No / Does the member have adequate cardiopulmonary status?
Yes / No / Is the member compliant with medical management?
Yes / No / Does the member have evidence of intolerance of total parenteral nutrition (TPN), including but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications, or the development of progressive but reversible liver failure?
Yes / No / Is the member HIV positive?
If Yes, continue to the next section.
Intestinal/Multivisceral Transplant Candidate in HIV Positive Member
Yes / No / Is the CD4 count greater than 200 cells per cubic millimeter for greater than 6 months?
If Yes, what is the level?
Yes / No / Is HIV-1 RNA undetectable?
Yes / No / Is the member stable on anti-retroviral therapy for more than 3 months?
Yes / No / Does the member have any other complications from AIDS [acquired immune deficiency syndrome] (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm?
If Yes, explain:
Isolated Small Bowel
Yes / No / Is the member TPN dependent?
If Yes, for how long?
Which of the following conditions is applicable for the member?
Multiple prolonged hospitalizations to treat TPN-related complications (e.g., repeated episodes of catheter-related sepsis)
Development of progressive liver failure
If Yes, explain:
Inability to maintain venous access
Kidney
Yes / No / Does the member have end-stage renal disease?
If Yes, what is the etiology/condition causing end state renal disease?
Yes / No / Is the member HIV positive?
If yes, continue to the next section.
Kidney Transplant Candidate in HIV Positive Member
Yes / No / Is the CD4 count greater than 200 cells per cubic millimeter for greater than 6 months?
If Yes, what is the level?
Yes / No / Is HIV-1 RNA undetectable?
Yes / No / Is the member stable on anti-retroviral therapy for more than 3 months?
Yes / No / Does the member have any other complications from AIDS [acquired immune deficiency syndrome] (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm?
If Yes, explain:
Liver
What is the member’s MELD/PELD score?
Yes / No / Does the patient have or had hepatocellular carcinoma beyond the liver?
Lung
Which procedure will the member receive?
Single Bilateral Living Lobar
Yes / No / Does the member have colonization with highly resistant or highly virulent bacteria, fungi or mycobacteria?
Yes / No / Does the member have irreversible, progressively disabling, end-stage pulmonary disease?
Heart-Lung
Which of the following conditions is applicable for the member?
Irreversible primary pulmonary hypertension with heart failure
Non-specific severe pulmonary fibrosis, with severe heart failure
Eisenmenger complex with irreversible pulmonary hypertension and heart failure
Cystic fibrosis with severe heart failure
Chronic obstructive pulmonary disease with heart failure
Emphysema with severe heart failure
Pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure
Pancreas and Pancreatic Islet Cells
Which procedure will the member receive?
Autologous pancreas islet cell
Simultaneous pancreas-kidney transplant (SPK)
Pancreas after kidney transplant
Pancreas transplant alone
Which of the following conditions is applicable for the member?
End stage renal disease (ESRD) and insulin-dependent diabetes for SPK
IDDM patient for pancreas transplant after prior kidney transplant (PAK)
Severely disabling and potentially life-threatening complications due to hypoglycemiaunawareness or labile diabetes that persists in spite of optimal medical management for PTA
(include documentation of hospitalizations, progress notes, and emergency room visits)
Yes / No / Does the patient have a consistent failure of insulin based management to prevent acute complications?
Yes / No / Does the patient have a history of frequent, acute and severe metabolic complications requiring recurrent hospitalizations?
Section E – Required Documentation
Check all boxes and complete all entries that apply:
The letter of medical necessity includes the following:Summary of course of illness
Current medications
Current smoking/alcohol/drug abuse or history
The medical records include the following:
History and physical with complete medical history
Pulmonary and cardiac clearances
Psychosocial assessment
Patient intake sheet with demographics
All radiology results
All diagnostic testing
Consultations
All laboratory results (chemistry, serology, recent toxicology screen, CD4 levels, infectious disease)
Additional Comments:
I hereby certify that (i) I am the treating physician for above member, (ii) the information contained in and included with this Certificate of Medical Necessity is true, accurate and complete to the best of my knowledge and belief, (iii) the member’s medical records contain all appropriate documentation necessary to substantiate this information. I acknowledge that a determination made based upon this Certificate of Medical Necessity is not necessarily a guarantee of payment and that payment remains subject to application of the provisions of the member’s health benefit plan, including eligibility and plan benefits. Additionally, I further acknowledge and agree that Florida Blue may audit or review the underlying medical records at any time and that failure to comply with such request may be a basis for the denial of a claim associated with such services.Ordering Physician’s Signature: / Date:
Certificate of Medical Necessity: Solid Organ Transplants1