F.No.S-14025/3/2010-MS/CGHS (P)
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi
Dated the 16th January, 2013
OFFICE MEMORANDUM
Subject :- Guidelines & Ceiling Rates for Liver Transplant Surgery in respect of CGHS / CS(MA) beneficiaries
With
reference to the above mentioned matter the undersigned is directed to
state that the Ministry of Health and Family Welfare has been receiving
requests from the Central Government employees and pensioners covered
under CGHS / CS(MA) Rules, 1944 seeking approvals for Liver
Transplantation surgery in respect of themselves and their eligible
family members under CGHS / CS(MA) Rules. The Ministry has been
examining these proposals on case to case basis for allowing the medical
treatment to the beneficiaries on merits. In view of the increasing
number of cases, the matter has been reviewed by this Ministry and it
has now been decided to issue guidelines and ceiling rates for
permission / reimbursement for Liver Transplant Surgery in respect of
CGHS / CS (MA) beneficiaries as per the details mentioned below: -
I. SELECTION CRITERIA
A. INDICATIONS
1. Adult Liver diseases
Acute liver failure | Non-Paracetamol (Viral, drug, induced, Wilson’s, Autoimmune hepatitis etc.) | Prothrombin time >100 sec or 3 of 5: Interval jaundice-encephalopathy > 7 days Age < 10 or > 40 Years Prothrombin time > 50 sec. / INR > 3.5 Bilirubin > 30 umol/1 Cause non-viral or unknown. |
Paracetamol induced | Arterial Ph <7.30 or all 3 criteria Encephalopathy grade III or IV Prothrombin time >100 sec./INR > 6.5 Creatinine >300 umol/I |
Chronic Liver disease | Cirrhosis (Non- Cholestatic) | Child-Pugh score >or equal 10 or Meld Score > 14 |
| Cholestatic with or without Cirrhosis | According to American criteria based on MELD scoring |
| Miscellaneous | case to case basis |
Liver Tumors | Heptocellular Carcinoma | Single Tumor <6.5 cm or Two Tumors < or equal 4.5 cm No Vascular invasion No distant Metastasis |
| Other types | Case to case basis |
2. Pediatric Liver diseases: - EHBA and Metabolic Liver Disease to be decided on case to case basis.
B. CONTRAINDICATIONS
Absolute | Systemic extra hepatic infcctions Extra hepatic malignancy (if not definitely cured) Irreversible brain damage Irreversible multi-organ failure Substance abusc ( if not abstinent for > 6 months) |
Relative | HIV seropositivity Age > 65 years Mental incapacity Extra hepatic disease limiting the chance of survival Residency outside India (unless emergency) |
II. Type of Transplant: permitted for reimbursement.
(a) Cadaveric donor
(b) Live donor
i.Related (Near Relatives)
ii. Unrelated (Only after approval by Authorization Committee)
III. Centres Approved for Liver Transplantation Surgery
Liver Transplant Surgery shall be allowed only in Government Hospitals/
Pvt. Hospitals, which are registered under the Transplantation of Human
Organs Act, 1994, as amended from time to time.
IV. Permission / ex-post facto approval for Liver Transplantation Surgery
The Liver Transplant Surgery will be permitted / reimbursed only after
the request has been approved and recommended by a Standing Committee,
comprising of the following:
1. | Addi. DG, CGHS/DDG (M) (as the case may be) | Chairman |
2 | HOD, GI Surgery, AIIMS | Member |
3. | HOD, Gastroenterology and Human Nutrition, | Member AIIMS |
4. | HOD, Gastroenterology, G.B. Pant Hospital | Member |
5 | HOD, GI Surgery, R&R Hospital | Member |
6. | HOD, Gastroenterology, R&R Hospital | Member |
7. | Joint Director (R & H), CGHS/Addl. DDG(MG-l1) | Member Secy. |
The above Standing Committee shall consider the cases in respect of CGHS as well as CS (MA) beneficiaries.
V. Documents required to be submitted for consideration of reimbursement / permission.
1. Recommendation by Govt. Gastroenterologist / GI Surgeon by at least one surgeons doing Liver Transplant Surgery.
2. CT /MRI Liver report.
3. Etiology evaluation report.
4. Histopathological report, wherever available
5. Current Child Pugh /MELD score report
6. Other relevant document.
VI. Reimbursement Criteria :-
As
Liver Transplant Surgery is a planned surgery and ther dore, prior
permission has to be obtained before the surgery is undertaken.
However,if for some reason it is done in emergency to save the life of
the patient, the Standing Committee shall consider the cases referred to
it for recommending grant of ex-post-facto permission on a case to case
basis.
VII. Submission of Application:
CGHS
/ CS (MA) beneficiaries will submit their request for permission for
Liver Transplant to the Standing Committee, through their respective
Department in case of serving employees and the Additional Director,
CGHS of the concerned zone or city, in case of pensioner CGHS
beneficiary. The Department concerned will refer the cases to the office
of Director, CGHS in case of a CGHS beneficiary and to the Medical
Services Division of Department of Health and Family Welfare in case of
CS (MA) beneficiaries for processing the case and its submission before
the Standing Committee for their consideration and recommendations.
VIII. Ceiling Rate for reimbursement for Liver Transplantation surgery under CGHS / CS(MA) rule.
(a) The package rate for Liver Transplantation surgery involving live liver donor shall be as follows:
Rs.
11,50,000/- ( Rupees Eleven lakh fifty thousand only) + pre transplant
evaluation of donor and recipient- Rs. 2,50,000/- (Rupees Two lakh fifty
thousand only).
(b) The package rate for Liver Transplant surgery involving a deceased donor shall be:
Rs. 11,00,000/- ( Rupees Eleven lakh only)
This includes, the cost of consumables during the organ retrieval and the cost of preservative solution, etc.
i) The package charges include the following
1. 30 days stay of the recipient and 15 days for the donor starting one day prior to the transplant surgery.
2.
Charges for Medical and Surgical Consumables, surgical and Procedure
Charges, Operation theater Charges, Anesthesia Charges, Pharmacy,
Investigations and in house doctor consultation for both donor and
recipient during the above period. This also includes all post operative
investigations and procedures during the above mentioned period.
ii) The package excludes:
1. Charges for drugs like Basiliximab/Daclizumab, HBIG, and peg Interferon.
2. Cross Matching charges for Blood and Blood products.
Note:
1. The extra stay if any may be reimbursed after justification by the
treating specialists for the reason of additional stay and only as per
CGHS guidelines.
2. The drugs mentioned above would be reimbursed as per CGHS rates or actual whichever is lower.
This Office Memorandum shall come into effect from the date of issue.
This
issues with concurrence of the Integrated Finance Division of
this Ministry vide their Diary No. C-1603 dated 26th December, 2012.
sd/-
[V.P. Singh]
Deputy Secretary to the Government of India
Source: www.msotransparent.nic.in
[http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File562.pdf]