PA 3 Transplant

Transplant
Prior Authorization Level 3 (PA-3) Request Form

Submission Instructions: Please complete this form and other sections as appropriate for transplant requests and
send it to the World Trade Center Health Program by posting it to the secure SFTP server and then sending an email
to [email protected] indicating the secure server posting of this request. Incomplete forms will be sent back
for more information. DO NOT FILL OUT NIOSH DECISION OR NIOSH DECISION RATIONALE.

General Member and Workup Information

Request Date

Member Type
Responder

Member Name

Member Date of Birth

Choose a CCE/NPN

Member 911#

Relevant Certified Condition

ICD Code

Relevant Certified Condition

ICD Code

Relevant Certified Condition

ICD Code

Significant Co-morbidities

Survivor

Letter of endorsement
from transplant
surgeon?

Current Smoker?

Yes

Yes

No

No
Other

Key Results of Viability Workup

CCE/NPN Requester Information

Requester Name

Requester Credentials

Requester E-mail

Requester Phone

Clinical Director Name (if not requester)

Clinical Director Concurrence Signature

Pre-Transplant workup/testing is documented properly (PA2) in member record.
Yes

No

Solid Organ Transplant Request

1. Requested Procedures and Services
Procedure/Service

NIOSH Decision

CPT Code

NIOSH Decision Rationale

Procedure/Service

NIOSH Decision

CPT Code

NIOSH Decision Rationale

Procedure/Service

NIOSH Decision

CPT Code

NIOSH Decision Rationale

Procedure/Service

NIOSH Decision

CPT Code

NIOSH Decision Rationale

NIOSH Decision

NIOSH Decision Rationale

Clinical Summary Please describe how the medical necessity rationale for the requested procedure(s)/
service(s) relates to the treatment or management of the certified WTC-related condition. Please summarize the
pre-transplant workup and the CMS qualified transplant facility transplant board recommendations. Please
document all other important transplant criteria noted in the WTCHP Policy and Procedures Manual Chapter 4,
Medical Benefits, Section 12: Transplants located at http://www.cdc.gov/wtc/ppm.html#4l and also what is noted
in the WTCHP Codebook guidelines.

3. Referral and Transplant Facility Information
Transplant Surgeon Name

Transplant Surgeon NPI

Transplant Facility Name

Transplant Facility NPI

Transplant Facility Address

Transplant Coordinator

Transplant Coordinator Contact (email/phone)

Referring Physician and Credentials

Referring Physician NPI

TO BE FILLED OUT BY A NIOSH
Name

NIOSH Decision

NIOSH Decision Comments

Credentials

Signature