Railway Medical Attendance Rules/RELHS: Guidelines and ceiling limit for Liver Transplant Surgery - Railway Board Order

GOVERNMENT OF INDIA

MINISTRY OF RAILWAYS

(RAILWAY BOARD)

No. 2010/H/6-1/POLICY (Liver Transplant)

New Delhi, dated :- 28.06.20l3

General Managers
All Indian Railways
(Including PUs).

Sub :- Guidelines and ceiling limit for Liver Transplant Surgery in respect of beneficiaries of Railway Medical Attendance Rules / RELHS.

The issue of laying down uniform guidelines to be adopted for Liver Transplant Surgery of Railway Health beneficiaries has been engaging attention of Ministry of Railways for sometime. After careful consideration of the matter, it has been decided to stipulate the under mentioned guidelines for adoption in all cases of Liver
Transplantation :-

1. Selection Criteria
A. Indications
(i). 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="" 3="" all="" br="" criteria="" encephalopathy="" grade="" iii="" iv="" nbsp="" or="">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	Hepatocellular Carcinoma	Single Tumor <6 .5="" 4.5="" br="" cm="" equal="" nbsp="" or="" tumors="" two="">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 infections 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)

2. Type of Transplant: permitted for reimbursement.
(a) Cadaveric donor
(b) Live donor
      i.Related
      ii. Unrelated

3. 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.

4. Documents required to be submitted for consideration of permission for liver transplant surgery
(i) Recommendation by Govt. / RIy. Gastroenterolgist/GI Surgeon.
(ii) CT/ MRI Liver report.
(iii) Etiology evaluation report.
(iv) Histopathological report, wherever available.
(v) Current Child Pugh/MELD score report.
(vi) Other relevant document.

5. Package Charges for Liver Transplantation Surgery
a) Package rate for Liver Transplantation Surgery involving live Liver donor shall be - Rs. 14,00,000/- (Rupees Fourteen Lakhs only). This would include Rs.2,50,000/- (Rupees Two Lakhs Fifty Thousand only) for pre-transplant evaluation of the donor and the recipient and Rs. 11,50,000/- (Rupees Eleven Lakhs Fifty Thousand only) for transplant surgery.

b) Package rate for Liver Transplant Surgery involving deceased donor shall be Rs.11,00,000/- (Rupees Eleven Lakhs only).

The above package includes the cost of consumables during the organ retrieval and the cost of preservative solution etc. The package charges also include the following:

(i) 30 days stay of the recipient and 15 days for the donor starting one day prior to the transplant surgery.

(ii) Charges for Medical and Surgical Consumables, surgical and procedure charges, Operation theatre charges, Anaesthesia Charges, Pharmacy charges etc.

(iii) Investigations and in-house doctor consultation for both donor and recipient during the above period of stay.

(iv) All post operative investigations and procedures during the above mentioned period.

C) The package shall exclude the following :-
Charges for drugs like Basiliximab/Daclizumab, HBIG, and peg interferon.Cross Matching charges for Blood and Blood products.

d) (i) The extra stay if any may be sanctioned/reimbursed after justification by the trcating specialists for the reason of additional stay and only as per Railway RMA/RELHS guidelines.

(ii) The drugs mentioned above would be reimbursed as per CGHS rates or actual whichever is lower.

6. Reimbursement Criteria:
As Liver Transplant Surgery is a planned surgery and, therefore, 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 medical board shall consider the case referred to it for recommending grant of ex-post-facto permission on a case to case basis.

7. Procedure for Sanction:
CMD of the zone shall nominate Medical Board comprising of a CMS/MD as the Chairman and two specialists each from Gastroenterology and GI Surgery as members which will recommend for Liver Transplantation. The proposal for financial sanction would be considered in consultation with finance of the zone and approval of General Manager before forwarding the same to Railway Board for sanction.

8. Other terms & conditions for payment of advance as per instructions laid down by this office from time to time will remain unchanged.

9. This issues with the concurrence of the Finance Dte. of Ministry of Railways.

10. These guidelines shall come into effect from the date of issue of this letter.

sd/-

(Dr.S.K. Sabharwal)

Executive Director, Health (G)

Railway Board

Source : NFIR