PhilHealth Benefit Package for Acute Lympliocytic (Lytnphoblastic) Leukemia (ALL), Breast Cancer, Prostate Cancer and Kidney Transplant

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

1.  The package code is Z002 which includes the following ICD-10 and RVS codes:

ICD 10	MANAGEMENT/PROCEDURES	CODES
D05 C50.0- C50.9	A.  Surgery    1.  Mastectomy	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, 36481

2.  The package rate shall be P100,000 for the entire course of treatment.

3.  Selection criteria for breast cancer:

1. Signed Member Empowerment (ME) Form
2. 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 T3N1N2M0

4.  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 Chemotherapy: 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 indicated

6.  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

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, 55865

2.  The package rate shall be P100,000 for the entire course of treatment.

3.  Selections criteria for prostate cancer:

1. Signed ME Form
2. Male patients age up to 70 years old
3. 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
4. Localized prostate cancer
5. No uncontrolled co-morbid conditions

4.  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.

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 Surgery: 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*

* Particulary given if no orchiectomy was done or when after orchiechtomy disease progresses needing more hormone intervention

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.

2.  The package rate shall be P600,000 for the entire course of treatment

3.  Selection criteria for kidney transplant:

1. Signed ME Form
2. Age >10 and <70 years
3. Single organ transplant
4. Patient on chronic dialysis because of end stage renal disease or patient for pre-emptive kidney transplantation. with the following:
1. The potential recipient should have an irreversible renal disease that has been progressive over the previous 6 -12 months.
2. 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
5. Low immunologic risk defined as:
1. Past Panel Reactive Antibody (PRA) less than or equal to 20%
2. Primary kidney transplant (no previous solid organ transplant)
3. No donor specific antibody (DSA) in the potential recipient
4. At least 1 HLA-DR match
6. 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
7. Transplant candidate who is CMV-negative cannot receive an organ from a CMV-positive donor.
8. 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)
9. 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.
10. 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 induction a.  Cyclosporine + mcycophenolate mofetil or mycophenolate sodium + prednisone b.  Tacrolimus + mycophenolate mofetil or mycophenolate sodium + prednisone 2.  Calcineurin inhibitor + mTOR inhibitor + prednisone with or without induction  a. Low-dose Cyclosporine + Sirolimus + prednisone b. Low-dose Cyclosporine + Everolimus + prednisone 3.  Calcineurin inhibitor + azathioprine + prednisone with or without induction   g.  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 therapy  1. Methylprednislolone 500mg IV/day x 3 days   j.  Post-transplant monitoring of donor and recipient

Graft renal biopsy of recipient if indicated Chest CT-scan Dipyridamole sestamibi scan Endoscopy Colonoscopy Pulmonary function test

5.  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 transplantation

6.  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.

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.