Guidelines and Ceiling limit for Liver Transplant Surgery under RELHS

Guidelines and Ceiling limit for Liver Transplant Surgery under Railway Medical Attendant – RELHS

Railway Board has increased the ceiling for the Liver Transplant Surgery under Railway Medical Attendant – RELHS

GOVERNMENT OF INDIA
MINISTRY OF RAILWAYS
(RAILWAY BOARD)

No. 2010/H/6-l/Policy[Liver Transplant). New Delhi, Dated:-25.05.2015,

General Managers,
All Indian Railways,
(Including PUs).

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

Ref:– i) This Office letter of even No. dated 28.06.2014.
ii) Board’s letter No. 2011/H/6-4/Policy-I dated 24.09.20.13.

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In order to bring clarity to the Zones while processing the sanction in Liver Transplantation Surgery cases in.. terms of RB’s letter dated 28.06.2013 and in terms of delegation of powers issued vide RB’s letter dated 24.09.2013, the existing Para 7 & Para 8 of Board’s letter dated 28.06.2013 have been consolidated and stands substituted as under:-

“7. CMD of the Zone shall nominate Medical Board comprising of CMS/MD as Chairman and two specialists each from Speciality of Gastroenterology /Internal Medicine and GI Surgery/ General Surgery as Members, which will recommend for Liver Transplant. The proposal for financial sanction would be considered with concurrence of Finance of the Zone and approval of GM. If the patient is to be referred to Government/Autonomous Body Hospital, GMs will have full powers to sanction medical advance (as delegated under Board’s letter No. 2011/H/6-4/Policy-I, dated 24.09.2013) subject to the ceiling limit/package rate for Liver Transplant Surgery as mentioned in Para 5 of Board’s letter dated 28.06.2013 or Hospital tariff, whichever is lower .. In case.: the patient is-undergoing Liver Transplantation Surgery in the recognized private hospital, the settlement has to be done as per bill system of payment within the ceiling package prescribed in Board’s letter dated 28.06.2013. However/ if the patient is proposed to be referred to a non-recognized private hospital for Liver Transplantation Surgery, the .proposal with due justification would require approval of Railway Board in terms of RB’s letter dated 24.09.2013,which will be processed subject to the ceiling limit/package rate as stipulated under Para-5 of Board’s letter dated 28.06.2013”.

Other provisions of Board’s letter dated 28.06.2013 will remain unchanged.

This issues with the approval of Finance Directorate in the Ministry of Railways.

(R.S. Shukla)
Dy. Director /Health,
Railway Board.

GOVERNMENT OF INDIA
MINISTRY OF RAJLWAYS
(RAILWAY BOARD)

No. 2010/B/6-1/Pollcy (Liver Transplant) New Delhi, dated:-28.06.2013

General Manager,

All Indian Railways (Including PUs).

Sub:- Guidelines and celling 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 tor 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. Instructions

(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 Jaundice-encephalopathy> 7 daysAge< 10 or >40 years Prothrombin time>50 sec./INR>3.5 Bilirubin>30 µmol/l Cause non-viral or unkown.
	Paracetamol induced	Arterial Ph<7.30 or all 3 criteria Encephalopathy grade III or IV Prothrombin time> 100 Sec./INR>6.5Creatinine >300 µmol/l
Chronic Liver Disease	Cirrhosis (Non-Cholestatic]	Child~Pugh score >= 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	Hepatocelluar Carcinoma	Single Tumor <6.5 cm or Two Tumors =< 4.5cm.. No Vascular invasion NNo distant Metastasis
	Other types	Case to case basis

(ii) Pediatric Liver diseases:- EBBA 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 damageIrreversible multi-organ failure

Relative

HIV seropositivityAge>65 years

Mental incapacity

Extra hepatic disease limiting the chance of survival

Residency outside India unless emergency

2. Type of Transplant: permitted for sanction of advance payment

(a) Cadaveric donor.

(b) Live donor

(i) Related

(ii) Unrelated

3. Centres approved for Liver Transplantation Surgery

Liver Transplantation 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./Rly. 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 treating 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 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.

Dr. S.K. Sabhirwal
Executive Director, Health (G)
Railway Board

GOVERNMENT OF INDIA
MINISTRY OF RAILWAYS
(RAILWAY BOAD)

No. 2011/H/6-4/Policy New Delhi, Date24 .09.2013

General Manager,
All Indian Railways including PUs.

Sub:- Delegation of powers to DRMs, AGMs, and GMs for sanction of expenses. of treatment of Railway Beneficiaries.

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The issue of further delegation of powers to DRMs, AGMs and GMs in the matter of sanction of medical advance, referral of Railway beneficiaries for non-recognised hospitals and sanction of medical reimbursement to the Railway beneficiaries has been engaging attention of Ministry of Railways for some time. After careful consideration in the matter and in super-cession of all existing instructions issued from time to time relating to sanction of advance/ referral of beneficiaries to non-recognised private hospitals and reimbursement of expenses incurred on treatment taken in emergency, the following delegation has been approved by the competent authority:-

Medical Advance

DRMs

To sanction referral in emergency to Govt. Hospitals including Autonomous body hospitals* and Medical Advance u to Rs. 50,000/- in each case.

AGMs-

I. To sanction referral of patients in emergency to private non recognized hospitals with sanction of advance upto Rs. 4 Lakhs in each case.II. Without any Financial ceiling limit if the patient is to be referred to a Government Hospital including Autonomous_ body* hospitals.

GMs-

I. “To sanction referral of patients in emergency to private non-recognized hospitals with sanction of advance upto Rs. 5 Lakhs in each case.II. Without any financial ceiling limit if the patient is to be referred to a Government Hospital including Autonomous body* hospitals.

III. To referral of patients for kidney transplant in Government /non- recognized private hospitals with sanction of advance up to Rs. 5 lakhs in each case subject to the condition that the amount to be sanctioned should not exceed CGHS package rate applicable in the city where the hospital is located

Medical Reimbursement

Authority	Delegated Powers
DRMs-	I. To sanction reimbursement up to Rs.25,000 /- per case, without any an annual ceiling limit, for treatment undertaken in emergency in private non- recognized hospitals .II. To sanction reimbursement up to Rs.50,000 /- per case, for treatment under taken in emergency in Government including Autonomous body* hospitals, without any annual ceiling limit
AGMs	To sanction medical reimbursement upto Rs. 4 lakh, for treatment taken in non-recognized private hospitals and without any limit for Government hospitals including Autonomous body* hospitals in emergency
GMs	To sanction medical reimbursement up to Rs.5 lakh, for treatment taken ID non-recognized private hospitals and without any limit for Government hospitals including Autonomous body* hospitals in emergency

* Autonomous body hospitals are those hospitals fully funded from Govt. Funds but given autonomy for administrative purposes like AIIMS,NIMS(Hyderabad).

2) The above delegation to Zonal Railways and Production Units is subject to the fulfillment of norms as prescribed in Railway Board’s letter No. 2005/H/6-4/Policy-II dated 31.01.2007 & 22.06.2010 being followed. These powers are delegated to the DRMs, AGMs & General Managers of Zonal Railways/Production Units only. These powers, however, may not be re-delegated further.

3) All such cases within the above delegation, which are still pending in Board’s office or in the Zonal Railway/PUs for sanction of competent authority, may be processed by the Zonal Railways/Production units at their end.

4) Claims over and above the ceiling limits, stipulated in para ( 1) above the provisions laid down there under, would continue to be referred to Railway Board for consideration.

5) This has sanction of Board and issues with the concurrence of Finance Directorate of Ministry of Railways.

6) ACS to para 648 and 651 of IRMM-2000 is enclosed.

(Dr. S.K. Sabharwal)
Executive Director, Health (G)
Railway Board.

S.No. 4 /Health/2013

Advance Correction slip for amendment of Para 648 of IRMM 2000.

The power of GM/ AGM/DRM for sanction of medical reimbursement claim for treatment taken in an emergency is as following:-

Authority	Delegate of Powers
DRMs-	To sanction reimbursernent upto Rs.25,000/- per case without any annual ceiling limit, for treatment undertaken in emergency in private non-recognized hospitalsTo sanction reimbursement up to Rs.50,000/- per case, for treatment undertaken in emergency in Government including Autonomous body* hospitals, without any annual ceiling limit.
AGMs	To sanction medical reimbursement upto Rs. 4 lakh, for treatment taken in non-recognized private hospitals, and without any limit for Government hospitals including Autonomous body” hospitals in emergency.
GMs	To sanction medical reimbursement upto Rs.5 lakh, for treatment taken in non-recognized private hospitals, and without any limit for Government hospitals including Autonomous body* hospitals in emergency.

Advance Correction slip for amendment of Para 651 of IRMM 2000.

The power of GM/AGM/DRM for sanction of medical advance is as following:-

Authority	Delegated Powers
DRMs-	To sanction referral in emergency to Govt. Hospitals including Autonomous body hospitals” and Medical Advance upto Rs. 50,000/• in each case.
AGMs-	I. To sanction referral of patients in emergency to private non-recognized hospitals with sanction of advance upto Rs. 4 Lakhs in each case.II. Without any Financial ceiling limit if the patient is to be referred to a Government Hospital including Autonomous body* hospitals
GMs	I. To sanction referral of patients in emergency t.o private non-recognized hospitals with sanction of advance upto Rs. 5 Lakhs in each case Without any financial ceiling limit if the patient is to be referred to a Government Hospital including Autonomous body” hospitals For referral of patients for kidney transplant in Government /non- recognized private hospitals with sanction of advance upto Rs. 5 lakhs in each case subject to the condition that the amount to be sanctioned should not exceed CGHS package rate applicable in the city where the hospital is located