Transplant services are covered as an optional medical service for New Mexico Medicaid recipients. Medicaid covers medically necessary services which are not considered unproven, investigational, or experimental for the condition for which they are intended or used as determined by HSD/MAD. Written prior approval must be obtained for all transplants, with the exception of corneas and kidneys (only transplants performed in New Mexico).
Requests for prior approval of transplant services are initiated by the recipient's attending physician via fax to Molina Healthcare TPA. It is the responsibility of the requesting physician to follow up the phone call with a written request. Extensive documentation will be required, including pertinent medical history, exams, indication of the non-experimental nature of the transplant, consultations (e.g., cardiology, nephrology), psycho-social evaluation, psychiatric evaluation (if appropriate), and a discharge and follow-up plan indicating who will assume care in the post-transplant period. Requesting providers are notified by fax of the review outcome.