(a) Subject to the specifications, conditions, and limitations established by the Health and Human Services Commission (HHSC), organ transplant services are covered as follows:
  (1) Coverage is limited to those services, as approved by HHSC or its designee, that are determined to be reasonable, medically necessary, and standard medical procedures.
  (2) Coverage includes solid and nonsolid organ procurement (including acquiring/harvesting, processing, preserving, storing, distributing, and tissue typing). If a hospital obtains an organ outside of the hospital, the hospital must obtain it from an organ procurement organization designated by the secretary of the Department of Health and Human Services. Coverage does not include donor expenses.
  (3) Coverage of each type of solid organ transplant is limited to an initial transplant and one subsequent retransplant because of rejection as a lifetime benefit.
(b) As specified by HHSC or its designee, prior authorization is required for certain organ transplant services. If a covered organ transplant has been prior authorized as medically necessary by HHSC or its designee because of an emergent, life-threatening situation, a maximum of 30 days of inpatient hospital services during a Title XIX spell of illness may be covered beginning with the actual first day of the transplant. This coverage is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30-day period is considered a separate inpatient hospital admission for reimbursement purposes. Physician services that HHSC or its designee determines to be reasonable and medically necessary are also covered during the 30-day period.
(c) If expenditures for a single inpatient hospital admission exceed the $200, 000 limit on hospitalization-related services specified in §354.1149 of this title (relating to Exclusions and Limitations), expenditures for that admission are excluded in calculating expenditures toward the limit. This policy only applies to an inpatient hospital admission to perform a covered organ transplant procedure determined to be medically necessary because of an emergent, life-threatening situation.
(d) To be reimbursed for transplant services, a hospital must meet the requirements included in the Social Security Act, §1138 and be approved and designated by HHSC as an organ transplant facility.
(e) For purposes of this section, the term "organ" means a human heart, kidney, liver, cornea, or bone marrow, and any other human organ or tissue specified by HHSC.

Source Note: The provisions of this §354.1175 adopted to be effective September 1, 1987, 12 TexReg 2579; amended to be effective April 13, 1988, 13 TexReg 1392; amended to be effective January 4, 1989, 13 TexReg 6292; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective November 28, 1996, 21 TexReg 11287; amended to be effective January 1, 1999, 23 TexReg 13076; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective October 27, 2013, 38 TexReg 7299