DMEPOS Mini-Series #7 – Immunosuppressive Drugs for Transplant

This month, we continue with our DMEPOS mini-series by discussing yet another challenging category –  immunosuppressive drugs for a transplant. Immunosuppressive drugs are only covered under Part B to maintain an organ transplant that was Medicare eligible. Immunosuppressives used for other diagnoses or indications that are not a transplant would not be covered under Part B and should be billed to Part D. Prescription Drugs used in immunosuppressive therapy are only covered if all the following five criteria are met:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

  1. Must be used for a covered transplant:
    1. Kidney, heart, liver, bone marrow/stem cell, lung, or intestinal
    2. Pancreas, in limited situations – See the Local Coverage Determination (LCD) link under PAAS tips for detailed requirements
  2. The transplant was performed at a Medicare-approved facility
  3. The beneficiary was enrolled in Part A at the time of the transplant
  4. The beneficiary was enrolled in Part B at the time the drugs were dispensed
  5. Delivery requirements – See the LCD link under PAAS tips for detailed requirements

Documentation needed upon an audit on immunosuppressive drugs for a transplant:

  1. Standard Written Order
    1. See our April 2021 Newsline, DMEPOS Documentation Requirements
  2. Medical Records
    1. Must indicate the date and location where the transplant occurred
    2. These records can be obtained from the original hospital discharge after the transplant or a current visit as long as the date and location are mentioned
    3. Pharmacies should maintain these records in the patient’s file for any future audits
    4. Continued need and use of immunosuppressive medication is established at the time of the transplant pending it continues to function successfully
  3. Proof of Refill Request (PORR – requirement if delivered or mailed) must contain:
    1. Name of the beneficiary, date of the request, description of item, quantity remaining or proof of exhaustion
    2. PORR may not be obtained more than 14 days before exhaustion of current supply or delivered/mailed to the patient more than 10 days before exhaustion
  4. Proof of Delivery
    1. See our June 2021 Newsline, DMEPOS Proof of Delivery and Refill Request Requirements

PAAS Tips:

  • Medicare limits the quantity on immunosuppressive drugs dispensed to a 30-day supply
  • Auto-immune disorders like arthritis, lupus and psoriasis can be treated with immunosuppressives
    • Medicare Part B does not pay for immunosuppressives for beneficiaries who do not meet the transplant coverage criteria, bill Medicare Part D instead
    • Document a diagnosis code on immunosuppressives that are being used for non-transplant indications when billing for Part D
  • See the LCD, checklists and other helpful forms and billing guidance under your DME MAC

Jennifer Ottman, CPhT
Latest posts by Jennifer Ottman, CPhT (see all)