When an energy employee with an accepted condition needs an organ or tissue transplant, the transplant provider asks DEEOIC for prior authorization on this form. It identifies the referring treating physician, the transplant facility and type, the organ transplant coordinator, and diagnosis and procedure codes. Three attachments are required: the treating physician's letter of medical necessity, initial and recent clinical evaluations, and the treatment protocol.
The transplant provider completes the form. Part D names the treating (referring) physician, whose letter of medical necessity describing the need for the transplant is a required attachment in Part G.
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Transplant Authorization Request
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A letter of medical necessity describing the need for the requested transplant. The transplant provider attaches it with the initial and recent clinical evaluation, such as diagnostic studies and laboratory tests, and a copy of the treatment protocol. Part D also lists the treating physician's name and address.
Up to four ICD diagnosis codes in item E1, using ICD-9 for services before October 2015 and ICD-10 after. Each service line points to those diagnoses and gives from and to dates with a CPT or HCPCS procedure code.