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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.

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:

• Bilateral bronchiectasis
• Alpha-1 antitrypsin deficiency
• Primary pulmonary hypertension
• Pulmonary fibrosis
• Cystic fibrosis (both lungs to be transplanted)
• Bronchopulmonary dysplasia
• Idiopathic pulmonary fibrosis
• Sarcoidosi
• Scleroderma
• Lymphangiomyomatosis-Lung
• Emphysema
• Eosinophilic granuloma
• Bronchiolitis obliterans
• Recurrent pulmonary embolism
• Pulmonary hypertension due to cardiac disease
• Chronic obstructive pulmonary disease
• Eisenmenger's syndrome
• Interstitial pulmonary fibrosis
• Emphysematous bleb

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. 

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 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
8. Coronary artery disease (CAD) not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function; or
9. Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.

*Some patients may be candidates for combined heart-lung transplantation

Patients must meet UNOS guidelines for lung allocation score (LAS) greater than zero.

Lung Specific
Bilateral lung transplantation is typically required when chronic lung infection disease is present, i.e., associated with cystic fibrosis and bronchiectasis. Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation.

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.

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."

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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