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A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s). Transplantation is an option for patients with end-stage lung disease.
End-stage lung disease may be the consequence of a number of different etiologies. The most common indications for lung transplantation are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. Prior to the consideration for transplant, patients should be receiving maximal medical therapy, including oxygen supplementation, or surgical options, such as lung-volume reduction surgery for COPD. Lung or lobar lung transplantation is an option for patients with end-stage lung disease despite these measures.
A lung transplant refers to single-lung or double-lung replacement. In a single-lung transplant, only one lung from a deceased 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 transplanted. Donors for lobar transplant have primarily been living-related donors, with one lobe obtained from each of 2 donors (eg, mother and father) in cases for which bilateral transplantation is required. There are also cases of cadaver lobe transplants. Combined lung-pancreatic islet cell transplant is being studied for patients with cystic fibrosis.
Since 2005, potential recipients have been ranked according to the Lung Allocation Score (LAS). Patients 12 years of age and older receive a score between 1 and 100 based on predicted survival after transplantation reduced by predicted survival on the waiting list; the LAS takes into consideration the patient’s disease and clinical parameters. In 2010, a simple priority system was implemented for children younger than age 12 years. Under this system, children younger than 12 years with respiratory lung failure and/or pulmonary hypertension who meet criteria are considered “priority 1” and all other candidates in the age group are considered “priority 2.” A lung review board has the authority to adjust scores on appeal for adults and children.
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 may be considered medically necessary for carefully selected patients with irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximum medical therapy including, but not limited to one of the conditions listed below.
A lobar lung transplant from a living or deceased donor may be considered medically necessary for carefully selected patients with end-stage pulmonary disease including, but not limited to one of the conditions listed below:
Lung or lobar lung retransplantation after a failed lung or lobar lung transplant may be considered medically necessary in patients who meet criteria for lung transplantation.
Lung or lobar lung transplantation is considered investigational in all other situations.
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.
The 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:
*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.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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."
09/16/2014: Policy reviewed; description updated. First medically necessary statement revised to state that lung transplantation may be considered medically necessary for carefully selected patients with irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximum medical therapy. Lobar policy statement revised to add that transplant may be from a living or deceased donor. Lobar policy statement list of conditions revised to remove pulmonary fibrosis and emphysematous bleb; added postinflammatory pulmonary fibrosis. Added the following policy statements: 1) Lung or lobar lung retransplantation after a failed lung or lobar lung transplant may be considered medically necessary in patients who meet criteria for lung transplantation. 2) Lung or lobar lung transplantation is considered investigational in all other situations.
02/16/2015: Policy description and statement unchanged. Policy guidelines updated to add "Policy-specific" to the list of potential contraindications subject to the judgment of the transplant center.
08/31/2015: Code Reference section updated for ICD-10. Corrected ICD-9 diagnosis code 415.2 to 415.12.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
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.