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DESCRIPTIONA lung transplant refers to single-lung or double-lung replacement. In a single-lung transplant, only one lung from a cadaver donor is provided to the recipient. In a double-lung transplant, the recipient's lungs are removed and replaced by the donor's lungs.
In a lobar transplant, a lobe of the donor's lung is excised, sized appropriately for the recipient's thoracic dimensions and is transplanted. Donors for lobar transplant have been primarily living related donors, with one lobe obtained from each of two donors (e.g. mother and father). In situations where a bilateral transplant is required, there are also cases of cadaver lobe transplants.
POLICYNo benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
Lung transplantation is medically necessary for carefully selected patients with irreversible, progressively disabling, end-stage pulmonary disease including, but not limited to one of the conditions listed below.
A lobar lung transplant is considered medically necessary for carefully selected patients with end-stage pulmonary disease including, but not limited to one of the conditions listed below:
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, lung and lobar lung transplant may be considered medically necessary. (See FEP policy)
For State and School Employee subscribers, all transplants must be certified as medically necessary by the Plan’s Utilization Review Vendor. No benefits will be provided for any transplant procedure unless prior approval for the transplant is obtained.
POLICY GUIDELINESPotential contraindications subject to the judgment of the transplant center:
*Some patients may be candidates for combined heart-lung transplantation
Patients must meet UNOS guidelines for lung allocation score (LAS) greater than zero.
Bronchiolitis obliterans is associated with chronic lung transplant rejection, and thus may be the etiology of a request for lung retransplantation.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy.
3/23/2006: Coding updated. CPT4 2006 revisions added to policy.
9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy
4/23/2009: Policy reviewed, no changes
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 416.2 added to covered table. ICD-9 procedure codes 32.3, 32.4, 32.5 deleted codes as of 9-30-2007 deleted from the covered table.
02/23/2011: Policy statement and guidelines updated to include specific contraindications for lung transplant.
02/24/2012: Deleted outdated references from the Sources section. Contraindications moved to the Policy Guidelines section, and the absolute and relative contraindications were combined. Deleted outdated references from the Sources section.
04/09/2013: Policy reviewed. In the lobar policy statement, "children and adolescents" was changed to "carefully selected patients."
SOURCE(S)Blue Cross Blue Shield Association policy # 7.03.07
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.