Medical Policy: 07.03.08
Original Effective Date: November 2009
Reviewed: November 2015
Revised: November 2015
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.
A combined heart/lung transplant is intended to prolong survival and improve function in patients with end-stage cardiopulmonary or pulmonary disease. The transplant 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.
Prior approval is required for all transplant services. Submit a prior approval now.
Heart/lung transplantation may be considered medically necessary for carefully selected patients with end-stage cardiac and pulmonary disease including, but not limited to, one of the following diagnoses:
- Pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure
- Emphysema with severe heart failure
- Eisenmenger complex with irreversible pulmonary hypertension and heart failure
- Cystic fibrosis with severe heart failure
- Non-specific severe pulmonary fibrosis
- Irreversible primary pulmonary hypertension with heart failure
- Chronic obstructive pulmonary disease with heart failure
- Alpha-1 Antitrypsin Deficiency
Except as defined above, candidates for heart/lung transplant should meet the following general criteria:
- Absence of active infection
- Absence of non-curable chronic extrapulmonary infection including chronic active viral hepatitis B, hepatitis C, and human immunodeficiency virus
- Documentation of patient compliance with medical management
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.
UNOS prioritizes donor thoracic organs according to the severity of illness with those patients who are most severely ill (status 1A) given highest priority in allocation of the available organs as follows:
Adult patients (=/> 18 years of age)
A patient is admitted to the listing transplant center hospital and has at least one of the following devices or therapies in place:
- Mechanical circulatory support for acute hemodynamic decompensation that includes at least one of the following:
- Left and/or right ventricular assist device implanted
- Total artificial heart
- Intra-aortic balloon pump
- Extracorporeal membrane oxygenator
- Mechanical circulatory support
- Mechanical ventilation
- Continuous infusion of inotropes and continuous monitoring of left ventricular filling pressures
- If the above criteria 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:
- Left and/or right ventricular device implanted
- Continuous infusion of intravenous inotropes
Patient meets at least one of the following criteria:
- Requires assistance with a ventilator
- Requires assistance with a mechanical assist device (e.g., extracorporeal membrane oxygenation [ECMO])
- Requires assistance with a balloon pump
- A patient less than 6 months old with congenital or acquired heart disease exhibiting reactive pulmonary hypertension at greater than 50% of systemic level. Such a candidate may be treated with prostaglandin E (PGE) to maintain patency of the ductus arteriosus
- Requires infusion of high-dose (e.g., dobutamine >/= 7.5 mcg/kg/min or milrinone >/= 0.50 mcg/kg/min) or multiple inotropes (e.g., addition of dopamine at >/= 5 mcg/kg/min)
Note: A patient who does not meet the criteria above may be listed as Status 1A if the patient has a life expectancy without a heart transplant of less than 14 days, such as due to refractory arrhythmia.
Patient meets at least one of the following criteria:
- Requires infusion of low-dose single inotropes (e.g., dobutamine or dopamine </= 7.5 mcg/kg/min)
- Less than 6 months old and does not meet the criteria for Status 1A
- Growth failure, i.e., + 5th percentile for weight and/or height, or loss of 1.5 standard deviations of expected growth (height or weight) based on the National Center for Health Statistics for pediatric growth curves
Note: Pediatric heart transplant candidates who remain on the waiting list at the time of their 18th birthday without receiving a transplant continue to qualify for medical urgency status based upon the pediatric criteria.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy
- Harringer W, Haverich A. Heart and heart-lung transplantation: standards and improvements. World J Surg 2002; 26(2):218-25.
- Reichart B, Gulbins H, Meiser BM et al. Improved results after heart-lung transplantation: a 17-year experience. Transplantation 2003; 75(1):127-32.
- United Network for Organ Sharing (UNOS). Policy 3.7. Organ Distribution: Allocation of Thoracic OrgansExternal Site. UNOS Policies and Bylaws. United Network for Organ Sharing, Alexandria, VA. December 2007.
- Orens JB, Estenne M, Arcasoy S et al. Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. 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; 25(7):745-55.
- Hayes D Jr, Galantowicz M, Hoffman TM. Combined heart-lung transplantation: A perspective on the past and the future. Pediatr Cardiol. 2012 Jun 10. [Epub ahead of print].
- The ISHLT Guideline For the Care of Heart Transplant Recipients (J Heart Lung Transplant 2010;29(8);424-453
November 2015 - Annual review, Policy Revised
December 2014 - Annual review, Policy Revised
February 2014 - Annual review, Policy Renewed
March 2013 - Annual review, Policy Renewed
March 2012 - Annual review, Policy Renewed
April 2011 - Annual review, Policy Renewed
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 © 2012 American Medical Association. All Rights Reserved.