QUEST Integration - Organ Transplants

QUEST Integration covers cornea transplants, and bone grafts for members who meet medical criteria for the services. See specific guidelines for cornea transplants below. The State of Hawaii Organ and Tissue Transplant (SHOTT) Program may cover other non-experimental or non-investigational organ or tissue transplants. See below for information on the state's program.

Cornea Transplants

Indications for lamellar keratoplasty include:

• Superficial layer corneal scarring and deformity due to trauma
• Aphakia
• High myopia
• High refractive error
• Keratoconus
• Recurrent pterygium

Additional conditions and limitations for lamellar keratoplasty:

• No intractable glaucoma in the eye under consideration
• No active eye infection at time of surgery
• No contraindications for surgery or anesthesia

Indications for penetrating keratoplasty include:

• Corneal pacification sufficiently obscuring vision through anterior segment of eye with at least light perception present. Causes for this problem include:
• Corneal injury and scarring
• Corneal degeneration (from Fuchs' or other dystrophy, or from previous cataract and/or intraocular lens implant)
• Corneal degeneration from keratoconus or familial causes
• Corneal infection (e.g. herpes)
• Therapeutic graft for relief of pain with at least light perception present, from corneal degeneration because of inflammation with pain in the eye and useful vision still present.

Additional conditions and limitations for penetrating keratoplasty are:

• No intractable glaucoma in the eye under consideration
• No active eye infection at time of surgery
• No contraindications for surgery or anesthesia

State of Hawaii Organ and Tissue Transplant Program

The state's Transplant Program evaluates potential candidates for other non-experimental or non-investigational organ or tissue transplants. These include:

• Kidney (as of July 2006)
• Liver
• Heart
• Lung
• Allogenic and autologous bone marrow

Children also may qualify for heart-lung and small bowel transplants, with or without liver.

For transplants to be covered under the state's Transplant Program, complete a Medicaid Form 1144 and submit it to DHS Medical Consultant, DHS Med-QUEST Integration Division, P.O. Box 339, Honolulu, HI 96809-0339. DHS will contact providers directly as they evaluate the individual as a potential transplant candidate. Qualified members will be moved from QUEST Integration to the Medicaid Program, which will arrange for the transplant and cover costs until the 12-month post-transplant period is completed.

Services Related to Transplants Not Covered by QUEST Integration

No payment is made for any service related to a transplant that is not covered by QUEST Integration, including donor work-up and harvesting of the tissue or organ. Certain services to treat complications arising from transplants not covered by QUEST Integration are limited to the following:

• Removal of the rejecting organ when the removal is precertified. Retransplantation and /or coverage for life-sustaining equipment or prosthesis (temporary or permanent) are not covered.
• Hospital services are limited to eligible charges from the date of the organ removal (if confinement was continuous from the date of the transplant), or the date of the readmission to remove the organ. Only charges related to the removal of the organ (operating room, room and board, ancillary) are covered.

Note: Coverage of complications applies only to transplants that are not considered experimental or investigative by the Food and Drug Administration.

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