Pursuant to PhilHealth Board Resolution No. 1629 s. 2012, and PhilHealth Circular No. 0129 s. 2012, "Governing Policies on PhilHealth Benefit Package for Case Type Z", the services and rates of the initial list of conditions under the Case Type Z benefit are hereby prescribed.
II. RULES FOR IDENTIFIED CASE TYPE Z
A. Only newly diagnosed cases of acute lymphocytic (lytnphoblastic) leukemia in children, breast cancer and prostate cancer shall be covered under the benefit package. For kidney transplant, only those that fit the inclusion criteria enumerated shall be covered.
B. The member must have paid at least three months of premium contributions within the immediate six months prior to the month of request For pro-authorization. For sponsored and OF\X' members and those individually paying members covered by a policy contract, the eligibility shall be based on the validity period of their membership cards/policy contracts.
C. Pre-authorization from Phili-Iealth based on the approved selections criteria per specific Case Type Z shall be required prior to availment of services. All requests for pre-authorization shall be approved/disapproved at the level of the Benefits Administration Section of the Philllealth Regional Office.
D. The diagnosis during pre-authorization shall be the basis For reimbursement.
E. No balance billing (NBB) policy shall be applied for eligible sponsored program members and their qualified dependents. Negotiated fixed co-pay shall be applied for eligible non-sponsored members and their qualified dependents. In no instance shall the fixed co-pay exceed the package rate.
F. The professional fees shall be 15% of the package.
G. Patients enrolled in the Case Type Z benefit will only be deducted five (5) days from the 45 days annual benefit limit regardless of the actual length of stay of the patient in the hospital. Such deductions shall be made on the current year and no deductions shall be made in the succeeding year. In cases where the remaining annual benefit limit is less than five (5) days, the member shall remain eligible to avail of the Case Type Z benefit.
H. Any complication/s arising during the hospital stay for the particular primary Z condition shall be part of the package.
I. Hospital confinements due to other causes as determined by the primary condition shall be paid separately.
J. All rates are inclusive of government taxes.
K. Rules on pooling of professional fees for government facilities shall still apply.
L. In cases when the patient expires anytime during the course of treatment or the patient is lost to follow up, the payment schedule for the specific treatment phase shall still be released as long as the patient has received the scheduled treatment. The remaining tranches shall not be paid.
M. A compilation of clinical guidelines/treatment protocols/clinical pathways shall be reflected in a separate issuance. The mandatory and other services of the specific Case Type Z conditions shall be given according to the scheduled protocols.
III. CASE TYPE Z
A. Standard Risk Acute Lymphocytic (lymphoblastic) Leukemia for Children
1. The package code is Z001 which includes the following ICD-10 and RVS codes:
ICD 10 MANAGEMENT/PROCEDURES CODES C91.0, M9821/3 Chemotheraphy 96408, 36488, 36481, 36640, 36660, 36510, 96450, 96542
2. The package rate shall be P210,000 for the entire course of treatment for three (3) years.
3. Selection criteria For ALL:
- Signed Member Empowerment (ME) Form
- Age 1 to less than 10 years old
- White blood cell count <50,000/µL
- No CNS leukemia at diagnosis
- There should be no testicular involvement of male patient at diagnosis
- WHO Classification: B or T lymphoblastic leukemia immunophenotype (mature B-cell ALL or Burkitt leukemia are excluded)4. The approved protocols on ALL contained in the compilation (as stated in the rules for identified Case Type Z) shall reflect the mandatory and other services as indicated in the table below.
MANDATORY SERVICES OTHER SERVICES
- Chemotherapy - vincristine, L-asparaginase, methotrexate (IV, IT and oral), 6-mercaptopurine, cyclophosphamide, cytarabine (IV and IT), etoposide, doxorubicin,
- Other drugs: dexamethasone, prednisone, folinic acid
- Antiemetics -ondansettton, metoclopramide
- Emergency medicines when necessary, such as epinephrine
- Pain medication - tramadol, morphine, and others
- Sedatives (prior to procedure): midazolam, nalbuphine, propofol, atropine, ketamine
- Laboratory and diagnostic procedures during the course of the treatment, including but not limited to: bone marrow examination with immunophenotyping, CSF analysis and cytospin, CBC, PT/PTT, BUN/Creatinine, ALT, bilirubin, uric acid, serum electrolytes, serum phosphorous, urinalysis, Chest X-ray, 2-D echocardiography and abdominal ultrasound
- Blood support - cross matching, screening, and processing
- Laboratory and diagnostic procedures
- Antimicrobials/antifungals depending on the sensitivity pattern of the particular contracted hospitals which includes the following (if indicated): meropenem, vancomycin, ceftazidime, ciprofloxacin, cefipime, piperacillin, tazobactam, fluconazole, amphotericin5. The payment for this package shall be two hundred ten thousand pesos (P210,000) for 3 years for the complete course of care which shall be given in three (3) tranches as follows:
B. Early Stage Breast Cancer (Stage 0 to III-A)
MODE OF PAYMENT AMOUNT FILING SCHEDULE 1st tranche (Z0011) P140,000.00 Within 60 days upon discharge after the 1st induction phase 2nd tranche (Z0012) P35,000.00 Within 60 days after the 3rd maintenance cycle 3rd tranche (Z0013) P35,000.00 Within 60 days after the 8th maintenance cycle
C. Low to Intermediate Risk Prostate Cancer Requiring Prostatectomy1. The package code is Z002 which includes the following ICD-10 and RVS codes:
ICD 10 MANAGEMENT/PROCEDURES CODES D05
99256, 99360, 19160, 19162, 19180, 19182, 19200, 19220, 19240, 76360, 76003, 76095, 76096, 76393 2. Lumpectomy 19120, 19125 B. Radiation Therapy 77401, 77418, 77421, 77261 C. Histopathology 88331, 88332, 88174 D. Chemotherapy 96408, 96440, 96445, 96450, 36488, 364812. The package rate shall be P100,000 for the entire course of treatment.3. Selection criteria for breast cancer:
- Signed Member Empowerment (ME) Form
- Clinical and TNM Staging:
- Stage 0 TisN0M0
- Stage IA T1N0M0
- Stage IB T0, T1N1M0
- Stage IIA T0, T1N1M0 or T2N0M0
- Stage IIB T2N1M0 or T3N0M0
- Stage IIIA T0, T1, T2N2M0 or T3N1N2M04. Stage IIIA becoming IIIB post-surgery which may require radiotherapy is included in this package.5. The approved protocols on breast cancer contained in the compilation (as stated in the rules for identified case type Z) shall reflect the mandatory and other services as indicated in the table below.
MANDATORY SERVICES OTHER SERVICES
- Baseline CBC, creatinine, FBX, calcium, AST/ALT, and ECG are done in preparation for treatment.
- Alkaline phosphatase, chest x-ray, abdominal ultrasound
- CP clearance and surgery
- Other diagnostic and laboratory procedures such as Estrogen Receptor/Progesterone Receptor (ER/PR) assay, HE2/neu expression, histopath/cytology, live ultrasound, creatinine
- For favorable risk profile breast cancers - Doxorubicin/Cyclophosphamide (AC)
- For unfavorable risk profile breast cancers - Doxorubicin, Cyclophosphamide, Docetaxel or Paclitaxel (ACT)
Hormonotherapy - For ER (+)/PR(+)/(-): if indicated, Tamoxifen or Atomatase Inhibitor Letrozole Antiemetics - ondansetron, metoclopramide
- Other drugs - dexamethasone, ranitidine, diphenhydramine
- Other diagnostic and laboratory procedures as indicated e.g. bone scan if the patient has symptoms related to bone or if there is elevated alkaline phosphatase level; CT scan of whole abdomen if abdominal ultrasound is inconclusive but there are symptoms referrable to the abdominal organs.
- Blood support - cross matching, screening
- Radiation therapy when indicated
- Fluorouracil and Methotrexate, if indicated
- Granulocyte stimulating factor and antibiotics, if indicated6. Reconstructive surgery shall not be covered under the Case Type Z.7. The payment for this package shall be one hundred thousand pesos (100,000) for one year only for the complete course of first line surgical and anti-cancer drug care with radiotherapy when indicated which shall be given in two (2) tranches as follows:
MODE OF PAYMENT AMOUNT FILING SCHEDULE 1st tranche (Z0021) P75,000.00 Within 60 days after discharge from surgery 2nd tranche (Z0022) P25,000.00 Within 60 days upon completion of last cycle of chemotherapy for Stage I to IIIA or upon completion of surgery for Stage 0
1. The package code is Z003 which includes the following 1CD-10 and RVS codes:
D. End Stage Renal Disease Eligible for Kidney Transplant (Low Risk)
ICD 10 MANAGEMENT/PROCEDURES CODES C61 Surgery 99256, 99360, 55801, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55859, 55866, 55873, 55700 Radiation therapy 77418, 77750, 77776, 77781, 77789, 55860, 55862, 558652. The package rate shall be P100,000 for the entire course of treatment.3. Selections criteria for prostate cancer:
- Signed ME Form
- Male patients age up to 70 years old
- Clinical stage (T1a-T2c), PSA level 10 to 20 ng/ml, Tumor Grade (Gleason's score oft-7)
- Low risk: T1-T2a and Gleason score 2-6, and PSA <10 ng/ml
- Intermediate risk: T2b to T2c, Gleason score of 7, and PSA 10-20 ng/ml
Localized prostate cancer No uncontrolled co-morbid conditions4. The approved protocols on prostate cancer contained in the compilation (as stated in the rules for identified case type Z) shall reflect the mandatory and other services as indicated in the table below.
* Particulary given if no orchiectomy was done or when after orchiechtomy disease progresses needing more hormone intervention
MANDATORY SERVICES OTHER SERVICES
- Prostatic specific antigen (PSA)
- Chest x-ray, bone scan, CT scan of pelvis and abdomen as indicated.
- Laboratory test (creatinine, FBS, calcium, alkaline phosphatase, AST/ALT, CBC, electrolytes, ECG, cholesterol, HDL, LDL, TG)
- CP Clearance
- Radical prostatectomy with orchiectomy
- Laparoscopic prostatectomy (ideally as the standard procedure of choice) with orchiectomy
- Radation therapy when indicated
- Other diagnostic procedures (as needed) - abodominal ultrasound, core needle biopsy
- Anti-androgen drugs, if indicated goserelin, bicalutamide, flutamide, leuprorelin*5. The payment for this package shall be one hundred thousand pesos (100,000) for one year only for the complete course of care, which shall be given in full upon discharge provided that any and all additional necessary treatment modalities will be given if indicated.
1. The package code is Z004 which includes the following ICD-10 and RVS codes:
ICD 10 MANAGEMENT/PROCEDURES CODES N18.0 Surgery 50320, 50340, 50360, 50365, 50370, 50200 Clearance 99256, 99360, 43234, 43235, 44388, 45355, 45378, 50200
2. The package rate shall be P600,000 for the entire course of treatment3. Selection criteria for kidney transplant:
- Signed ME Form
- Age >10 and <70 years
- Single organ transplant
- Patient on chronic dialysis because of end stage renal disease or patient for pre-emptive kidney transplantation. with the following:
- The potential recipient should have an irreversible renal disease that has been progressive over the previous 6 -12 months.
- The recipient's measured (nuclear scan) glomerular filtration rate, 24-hour urine creatinine clearance or calculated glomerular filtration rate should be less that 20 ml/min /1.73m2 in diabetics or less than 15 ml/min /1.73m2 in patients with non-diabetic renal disease
- Low immunologic risk defined as:
- Past Panel Reactive Antibody (PRA) less than or equal to 20%
- Primary kidney transplant (no previous solid organ transplant)
- No donor specific antibody (DSA) in the potential recipient
- At least 1 HLA-DR match
- Potential recipient has no previous history of cancer (except basal cell skin cancer) , should be HIV negative, Hepatitis B surface antigen negative, and Hepatitis C antibody negative
- Transplant candidate who is CMV-negative cannot receive an organ from a CMV-positive donor.
- Absence of current severe illness (Congestive heart failure Class 3-4, liver cirrhosis (findings of small liver with coarse granular/heterogeneous echo pattern with signs of portal hypertension), chronic lung disease requiring oxygen, etc)
- Absence of the following: hemi-paralysis because of stroke, leg amputation because of peripheral vascular disease or diabetes, mental retardation such that informed consent cannot be made, and substance abuse for at least 6 months prior to start of transplant work-up.
- Eligible patient for kidney transplant must have a certification from the social service of the hospital that they can maintain anti-rejection medicines for the next, three (3) years.4. The approved protocols on kidney transplant contained in the compilation (as stated in the rules for identified case type Z) shall reflect the mandatory and other services as indicated in the table below.
MANDATORY SERVICES OTHER SERVICES
- CP-clearance for donor (if indicated) and recipient
- Pre-Transplant evaluation/labs (Phases 1, 2, 3, and 4) for donor and recipient candidates
- Transplantation Surgery with living donor or deceased donor
- Hemodialysis or Peritoneal dialysis during admission for transplantation
- Immunosuppressant induction therapy
- Immunologic risk - At least 1 Donor Recipient match, Primary kidney transplant, Single organ transplant, PRA <20%Immunosuppression options:1. Calcineurin inhibitor + mycophenolate + prednisnone with or without inductiona. Cyclosporine + mcycophenolate mofetil or mycophenolate sodium + prednisone2. Calcineurin inhibitor + mTOR inhibitor + prednisone with or without induction
b. Tacrolimus + mycophenolate mofetil or mycophenolate sodium + prednisonea. Low-dose Cyclosporine + Sirolimus + prednisoneb. Low-dose Cyclosporine + Everolimus + prednisone3. Calcineurin inhibitor + azathioprine + prednisone with or without inductiong. Induction therapies
1. Interleukin-2 receptor blockers, Basilixmab 20mg IV x 2 doses
2. Lymphocyte depleting agents
a. Alemtuzumab 30 mg IV dose
b. Rabbit antithymocyte globulin 1-1.5 mg/kg/day x 3 doses
h. Anti-rejection therapy1. Methylprednislolone 500mg IV/day x 3 daysj. Post-transplant monitoring of donor and recipient
- Graft renal biopsy of recipient if indicated
- Chest CT-scan
- Dipyridamole sestamibi scan
- Pulmonary function test5. The payment for this package shall be six hundred thousand pesos (600,000) for one year only for the complete course of care which shall be given in three (3) tranches as follows:
MODE OF PAYMENT AMOUNT FILING SCHEDULE 1st tranche (Z0031) P550,000 Within 60 days upon discharge of recipient after the transplantation 2st tranche (Z0032) P50,000 Ninety (90) days after the transplantation6. Those who will avail of this package shall not be eligible for package for dialysis or transplantation benefits in the next five (5) years.7. All laboratories for medical evaluation of donor and transplant candidates shall be performed in the transplant facility. In cases where the transplant facility is not capable to provide a specific laboratory test indicated either under Mandatory or Other Services, such facility must contract with another licensed facility wherein such laboratory test is available. In such a case, the transplant facility shall pay the contracted facility for the services provided. In no case shall the patient be required to pay out of pocket for such outsourced services.
IV. CLAIMS FILING
All claims shall be filed by the contracted hospitals on behalf of the patient through Z claims provided that requirements are met based on the filing schedule for the Z conditions to he articulated in a separate issuance. During the transition period while the information system for the Case Type Z, pre-authorization and filing of claims shall be done manually. Guidelines for filing of claims shall be issued in a separate circular.