Kidney Transplant Information Checklist

Service Type: 0300

Provider Contact Name:      Provider NPI #       Phone Number    -   -    
Facility Name where transplant will occur:       NPI#      
Is this a Retro Review: Yes No
All 0300 requests will be entered into Atrezzo system under Physician NPI

1. End-stage renal disease (ESRD): Yes No

2. On dialysis or GFR < 20? Yes No

3. Cardiac screen? Yes No

4. History of CAD? Yes No

5. If the answer to 4 is yes, has the member been cleared by cardiologist for transplant? Yes No

6. GI screen? Yes No

7. Any GI diseases? Yes No

8. If the answer to 7 is yes, please list the GI disease:      

9. If the answer to 7 is yes, has the member been cleared by surgeon / gastroenterologist?
Yes No

10. Liver screen? Yes No

a. Normal serum transaminases and total bilirubin? Yes No

b. Hepatitis serologies negative? Yes No
11. Genitourinary Screen? Yes No

12. Genitourinary diseases? Yes No

13. If the answer to 12 is yes, please list the genitourinary disease:      

14. GU disease test results were: Negative Positive

15. Are there minor GU abnormalities? Yes No

16. GU disease was treated? Yes No

17. If the answer to 16 is no, please explain:      

18. Will adequate supervision will be provided to assure there will be strict adherence to the medical
regimen which is required: Yes No

19. Medical management has failed and the transplant likely to prolong life and restore a range of physical
and social function suited to activities of daily living? Yes No

Created April 2012

 Kidney Transplant Information Checklist

20. Is there a history of drug abuse? Yes No

21. Is there a history of alcohol abuse? Yes No

22. Is there a history of smoking? Yes No

23. If the answer to 15 is yes, has there been a drug free period? If yes, how long?      

24. If the answer to 16 is yes, has there been an alcohol free period? If yes, how long?      

25. If the answer to 17 is yes, has there been a smoke free period? If yes, how long?      

26. Is there a behavioral health disorder by history and PE? Yes No

27. If the answer to 26 is yes, has the behavioral health disorder been treated? Yes No

28. Is there adequate social /family support? Yes No

29. Is there a history or a current serious issue with non-compliance with medical treatment? Yes No

30. The facility performing the transplant with appropriate credentials and expertise has evaluated the
member and has indicated the willingness to undertake the procedure: Yes No

31. Psychosocial evaluation completed documenting the mental stamina to comply with post transplant
treatments: Yes No

32. Patient understanding of surgical risk and post procedure compliance and follow−up? Yes No

Out of State Providers

1. Please select one of the four responses which best meets the reason you are requesting
Out of State Provider Services and specify how the request meets the selected reason:

Services provided out of state for circumstances other than these specified reasons shall
not be covered.

The medical services must be needed because of a medical emergency;

Medical services must be needed and the Member's health would be endangered if he were
required to travel to his state of residence;

The state determines, on the basis of medical advice, that the needed medical services, or
necessary supplementary resources, are more readily available in the other state;

It is the general practice for Members in a particular locality to use medical resources in
another state.

Explain selected response:      

Created April 2012

 Kidney Transplant Information Checklist

2. Enrolled in Virginia Medicaid: Yes No

Out of state providers may enroll with Virginia Medicaid by going to:

https://www.virginiamedicaid.dmas.virginia.gov/wps/myportal/ProviderEnrollment. At the top of the

page, click on Provider Services and then Provider Enrollment in the drop down box. It may take up to 10
business days to become a Virginia participating provider.

Created April 2012