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A combined heart/lung transplant is intended to prolong survival and improve function in patients with end-stage cardiopulmonary or pulmonary disease. The technique involves a coordinated triple operative procedure consisting of procurement of a donor heart-lung block, excision of the heart and lungs of the recipient, and implantation of the heart and lungs into the recipient.

A heart/lung transplant refers to the transplantation of one or both lungs and heart from a single cadaver donor.

Heart/lung transplantation is medically necessary for carefully selected patients with end-stage cardiac and pulmonary disease including, but not limited to, one of the following diagnoses:

• irreversible primary pulmonary hypertension with heart failure;
• non-specific severe pulmonary fibrosis, with severe heart failure;
• Eisenmenger complex with irreversible pulmonary hypertension and heart failure;
• cystic fibrosis with severe heart failure;
• chronic obstructive pulmonary disease with heart failure;
• emphysema with severe heart failure;
• pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure.

None

Potential contraindications subject to the judgment of the transplant center:

1. Known current malignancy, including metastatic cancer
2. Recent malignancy with high risk of recurrence
3. Untreated systemic infection making immunosuppression unsafe, including chronic infection
4. Other irreversible end-stage disease not attributed to heart or lung disease
5. History of cancer with a moderate risk of recurrence
6. Systemic disease that could be exacerbated by immunosuppression
7. Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

When the candidate is eligible to receive a heart in accordance with United Network for Organ Sharing (UNOS) guidelines for cardiac transplantation, the lung(s) shall be allocated to the heart-lung candidate from the same donor. When the candidate is eligible to receive a lung in accordance with the UNOS Lung Allocation System (LAS), the heart shall be allocated to the heart-lung candidate from the same donor if no suitable Status 1A isolated heart candidates are eligible to receive the heart. Status 1A is described below. (3)

Cardiac Specific

The United Network for Organ Sharing (UNOS) prioritizes donor thoracic organs according to the severity of illness as follows:

Status 1A

A patient is admitted to the listing transplant center hospital and has at least 1 of the following devices or therapies in place:

(a) Mechanical circulatory support for acute hemodynamic decompensation that includes at least 1 of the following:

1. Left and/or right ventricular assist device implanted
2. Total artificial heart
3. Intra-aortic balloon pump: or
4. Extracorporeal membrane oxygenator (ECMO)

(b) Mechanical circulatory support

(c) Mechanical ventilation

(d) Continuous infusion of inotropes and continuous monitoring of left ventricular filling pressures

(e) If criteria a, b, c, and d are not met, such status can be obtained by application to the applicable Regional Review Board

Status 1B

A patient has at least 1 of the following devices or therapies in place:

1. left and/or right ventricular device implanted, or
2. continuous infusion of intravenous inotropes

A patient that does not meet Status 1A or 1B is listed as Status 2.

Status 7 patients are considered temporarily unsuitable to receive a thoracic organ transplant.

5/1/2002: Type of Service and Place of Service deleted

7/21/2005: Reviewed by MPAC: "HIV positivity is not an absolute contraindication to transplant.  Each individual transplant center will determine patient selection criteria for HIV positive patients."    

10/17/2005: Code Reference table updated: codes: 33930, 33960 description revised, 33933 added; diagnosis codes 277.0-277.01, 416.2 deleted, 277.02, 416.0, 491.20, 491.22, 493.20, 493.21, 493.22 added; ICD-9 procedure 00.93 added. 

3/28/2006: Coding updated:  CPT4 2006 revisions added to policy

12/31/2008: Policy reviewed, prior authorization for evaluation removed.

02/24/2012:  Policy statement revised to add "with severe heart failure" to the second bullet point. Deleted the following from the policy statement: HIV positivity is not an absolute contraindication to transplant.  Each individual transplant center will determine patient selection criteria for HIV positive patients.  Contraindications moved to the Policy Guidelines section, and the absolute and relative contraindications were combined. Deleted outdated references from the Sources section.

03/13/2013:  Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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