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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.
POLICYNo benefits will be provided for a covered transplant procedure unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
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:
Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessary in patients who meet criteria for heart/lung transplantation.
Heart/lung transplantation is considered investigational in all other situations.
POLICY GUIDELINESThe coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Potential contraindications subject to the judgment of the transplant center:
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)
The United Network for Organ Sharing (UNOS) prioritizes donor thoracic organs according to the severity of illness as follows:
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:
(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
A patient has at least 1 of the following devices or therapies in place:
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.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
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.
04/07/2014: Policy statement updated to add "Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessary in patients who meet criteria for heart/lung transplantation." Added statement that heart/lung transplantation in all other situations is considered investigational.
SOURCE(S)Blue Cross Blue Shield Association policy #7.03.08
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.