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Medical Policy: 07.03.06
Original Effective Date: November 2009
Reviewed: April 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
The primary goal of lung transplantation is extended survival. For most patients lung transplant is a palliative rather than curative treatment intended for patients with end-stage lung disease who have failed to respond to alternative medical or surgical treatment.
The type of lung transplant is based upon the patient’s condition and the indication for transplant. Living-donor lobar-lung transplant refers to the transplantation of either the right or left lower lobe from one or two healthy donors to replace one or both lungs. The procedure was devised to assist in alleviating the limited availability of cadaveric lungs and thereby prolong survival in patients who are likely to die before a cadaveric organ becomes available.
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Prior Approval:
Prior approval is recommended. Submit a prior approval now.
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Policy:
Lung or lobar lung transplantation may be considered medically necessary in patients with end-stage disease of lung parenchyma, airway and pulmonary vasculature that is not amenable to maximum alternative medical and surgical therapies when one the following criteria are met:
- Less than 50%, 2- to 3- year predicted survival
- Severe, progressive symptoms with a functional status of New York Heart Association (NYHA) class III or IV despite optimal medical management, resulting in an unacceptable quality of life
Categories of lung disease for which transplant may be indicated include, but are not limited to:
- Restrictive lung diseases such as idiopathic pulmonary fibrosis, pulmonary fibrosis from other causes, interstitial lung disease, sarcoidosis, asbestosis
- Chronic obstructive lung diseases such as emphysema, alpha-1 antitrypsin deficiency, chronic bronchitis, bronchiolitis obliterans, lymphangioleiomyomatosis
- Septic lung diseases such as cystic fibrosis, bronchiectasis
- Pulmonary vascular diseases such as pulmonary hypertension, Eisenmenger syndrome, recurrent pulmonary embolism
Lung and lobar lung transplant is considered not medically necessary for patients with the following contraindications:
- Persistent, recurrent or unsuccessfully treated major or systemic infections
- Systemic illness or comorbidities that would be expected to substantially negatively impact the successful completion and/or outcome of transplant surgery
- Untreatable advanced dysfunction of another organ system such as heart, liver, or kidney disease
- Coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function
- Significant chest wall deformity
- A pattern of noncompliance which would place a transplanted organ at serious risk of failure
The evaluation of a transplant candidate who has a history of cancer must consider the prognosis and risk of recurrence from available information including tumor type and stage, response to therapy, and time since therapy was completed. Although evidence is limited, patients in whom cancer is thought to be cured should not be excluded from consideration for transplant. UNOS has not addressed malignancy in current policies.
The United Network for Organ Sharing (UNOS) believes that asymptomatic HIV-positive patients should not necessarily be excluded for candidacy for organ transplantation, stating, “A potential candidate for organ transplantation whose test for HIV is positive but who is in an asymptomatic state should not necessarily be excluded from candidacy for organ transplantation, but should be advised that he or she may be at increased risk of morbidity and mortality because of immunosuppressive therapy.” In 2001, the Clinical Practice Committee of the American Society of Transplantation proposed that the presence of AIDS could be considered a contraindication to kidney transplant unless the following criteria were present. These criteria may be extrapolated to other potential organ transplants:
- CD4 count ≥ 200 cells/mm-3 for > 6 months
- HIV-1 RNA undetectable
- On stable anti-retroviral therapy > 3 months
- No other complications from AIDS (e.g., opportunistic infection including aspergillus, tuberculosis, coccidioses mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm)
- Meeting all other criteria for organ transplantation
It is likely that each individual transplant center will have explicit patient selection criteria for HIV-positive patients.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 32850; Donor pneumonectomy(s) (including cold preservation), from cadaver donor
- 32851; Lung transplant, single; without cardiopulmonary bypass
- 32852; Lung transplant, single; with cardiopulmonary bypass
- 32853; Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass
- 32854; Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
- 32855; Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral
- 32856; Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral
- S2060; Lobar lung transplantation
- S2061; Donor lobectomy (lung) for transplantation, living donor
- S2152; Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre and posttransplant care in the global definition
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Selected References:
- American College of Chest Physicians. A guide to lung transplantation. 2006 Available at http://www.chestnet.org/downloads/patients/guides/LungTransplantation.pdf. Accessed October 24, 2009.
- Aurora P, Carby M, Sweet S. Selection of cystic fibrosis patients for lung transplantation. Curr Opin Pulm Med. 2008 Nov;14(6):589-94.
- Kaza AK, Dietz JF, Kern JA et al. Coronary risk stratification in patients with end-stage lung disease. J Heart Lung Transplant. 2002 Mar;21(3):334-9.
- Chang AC, Chan KM, Lonigro RJ et al. Surgical patient outcomes after the increased use of bilateral lung transplantation. J Thorac Cardiovasc Surg. 2007 Feb;133(2):532-40. [Epub Dec 29, 2006]
- Steinman TI, Becker BN, Frost AE et al. Clinical Practice Committee, American Society of Transplantation. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001 May 15;71(9):1189-204.
- Kozower BD, Meyers BF, Smith MA et al. The impact of lung allocation score on short-term transplantation outcomes: a multicenter study. J Thorac Cardiovasc Surg 2008;135(1):166-71.
- Orens JB, Garrity ER Jr. General overview of lung transplantation and review of organ allocation. Proc Am Thorac Soc 2009;6(1):128-36.
- Orens JB, Estenne M, Arcasoy S et al. International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update-A Consensus Report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2006 Jul; 25(7):745-55.
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Policy History:
Date Reason Action
April 2011 Annual review Renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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