TN 31 (06-04)
HI 00801.221 Date of Entitlement - Transplant
1. R-HI based on transplant
R-HI can begin on the basis of a kidney transplant whether or not the patient has been on renal dialysis prior to the transplant. Where there is no course of dialysis that would result in earlier entitlement, R-HI begins with the month of transplant (even if the patient dies during the transplant surgery) or, in “early entitlement (transplant)” cases, as many as 2 months prior to the month of transplant, as explained in HI 00801.221.A.2.
For entitlement purposes, the transplant does not have to take place in a hospital approved by Medicare as a transplant hospital, e.g., the hospital may be located outside the United States. However, Medicare payment is not made for services unless they take place in a Medicare-approved facility.
2. Early entitlement (transplant)
R-HI based on transplant can also begin:
with the month in which the individual is an inpatient in a hospital that is an approved renal transplantation center or in a hospital that is an approved renal dialysis center in anticipation of, or in preparation for, transplant surgery, provided such surgery takes place within the next 2 months; or
with the second month prior to the month of transplant if the above condition was met but the transplant occurred more than 2 months after the preparatory services occurred.
The inpatient stay for preparatory services does not have to be continuous from the time the decision is made to proceed to transplant until the transplant occurs.
NOTE: For early entitlement (transplant) cases, the facility must be Medicare-approved.
3. Death during transplant surgery
If the individual dies before the transplantation surgery can take place, the requirements for entitlement based on transplant are not met. However, death during the transplantation surgery does not preclude entitlement (including early entitlement) based on transplant.
1. Surgery within 2 months
Mrs. Falcone began a regular course of dialysis in 12/01. She was admitted to an approved transplant hospital on 1/31/02 for transplant surgery which occurred in 2/02. Since Mrs. Falcone is fully insured and filed a timely application, R-HI begins 1/1/02, the first day of the month she was admitted to a hospital for transplant surgery. If she had been admitted one day later, on 2/1/02, her entitlement would be effective 2/1/02.
2. Surgery after 2 months
Mr. Simmons, a fully insured individual, was admitted to a hospital in 4/02 with severe kidney problems. He was not diagnosed as having ESRD until 5/02. He received preliminary procedures to prepare him for a transplant, was started on a regular course of dialysis and sent home. In 7/02, he was readmitted to the hospital and received a transplanted kidney.
Mr. Simmons is entitled to R-HI effective 5/1/02, since in that month he was in a hospital being prepared for transplant surgery and had such surgery within 2 months. (If the transplant had to be delayed until 8/02, his entitlement could not begin until 6/1/02, the second month prior to the month of transplant.)