ModifiedAmbetter GeorgiaPolicy CP.MP.132

Heart‑lung transplant coverage criteria

Customize your policy alerts

Sign up for Ambetter Georgia Policy CP.MP.132 alerts

Get alerted when Policy CP.MP.132 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity criteria and coverage guidance for combined heart‑lung transplantation for Ambetter Georgia members, describing indications, contraindications, and coding implications for providers and transplant centers.

Policy Summary

PayerAmbetter Georgia

PolicyHeart‑lung transplant coverage criteria

Policy CodePolicy CP.MP.132

Change TypeMultiple material revisions to indications, contraindications, age groupings, and criteria language

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document candidate evaluation against the policy criteria (age group, nutritional status, substance use, and contraindications) before proceeding.

SourceLink

POLICY UPDATE CHANGES

Added the term 'pulmonary' to I.A.2.d.

Changes made to I.A.2.h and addition of subsections h.i.-v.

Ages changed in I.B.1.a. to '> 18' and I.B.1.b. to '≤ 18'.

In I.C.1.a, added 'for at least …transplantation'.

Added I.C.1.d specifying 'Member/enrollee…severe malnutrition'.

In I.C.8., added 'unless being…transplant'.

Reworded I.C.16.a to reflect 'alcohol or illicit drug use'.

Updated criteria I.A.1.h.iv. and I.A.2.h.iv. from '…could preclude heart failure in the future…' to '…could preclude heart transplant in the future...'.

Removed indication I.A.2.d., pulmonary alveolar proteinosis.

Removed serial blood and urine testing details in Criteria I.C.16.

Table 2 changed to the American Heart Association Heart Failure Stages, removing Pediatric Heart Disease stages; Table 2 updated for clarity.

Background reviewed and updated; coding verified; internal and external specialist reviewed.

≥18 / <18Age‑based indication groupings

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedAmbetter GeorgiaPolicy CP.MP.132

Heart‑lung transplant coverage criteria

Customize your policy alerts

Sign up for Ambetter Georgia Policy CP.MP.132 alerts

Get alerted when Policy CP.MP.132 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Georgia

PolicyHeart‑lung transplant coverage criteria

Policy CodePolicy CP.MP.132

Change TypeMultiple material revisions to indications, contraindications, age groupings, and criteria language

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document candidate evaluation against the policy criteria (age group, nutritional status, substance use, and contraindications) before proceeding.

SourceLink

POLICY UPDATE CHANGES

Added the term 'pulmonary' to I.A.2.d.

Changes made to I.A.2.h and addition of subsections h.i.-v.

Ages changed in I.B.1.a. to '> 18' and I.B.1.b. to '≤ 18'.

In I.C.1.a, added 'for at least …transplantation'.

Added I.C.1.d specifying 'Member/enrollee…severe malnutrition'.

In I.C.8., added 'unless being…transplant'.

Reworded I.C.16.a to reflect 'alcohol or illicit drug use'.

Updated criteria I.A.1.h.iv. and I.A.2.h.iv. from '…could preclude heart failure in the future…' to '…could preclude heart transplant in the future...'.

Removed indication I.A.2.d., pulmonary alveolar proteinosis.

Removed serial blood and urine testing details in Criteria I.C.16.

Table 2 changed to the American Heart Association Heart Failure Stages, removing Pediatric Heart Disease stages; Table 2 updated for clarity.

Background reviewed and updated; coding verified; internal and external specialist reviewed.

≥18 / <18Age‑based indication groupings

Coverage Criteria for Heart‑Lung Transplant

Initial transplant eligibility

Covered when ALL of the following are met

Overall: Member meets A, B, and C below

A. Indication: End-stage heart and end-stage lung disease due to specified diagnoses: Age-stratified diagnostic lists qualify. For age ≥ 18: irreversible primary pulmonary hypertension with severe heart failure; nonspecific idiopathic severe pulmonary fibrosis; Eisenmenger syndrome with irreversible pulmonary hypertension and heart failure; cystic fibrosis with severe heart failure; chronic obstructive pulmonary disease with severe heart failure; emphysema with severe heart failure; pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure; congenital heart disease (CHD) meeting specified subcriteria including single ventricle CHD with Fontan circulation and related high-risk features (symptomatic HF with reduced systolic function; symptomatic HF with preserved systolic function and abnormal filling pressures; refractory lymphatic abnormalities including plastic bronchitis and protein-losing enteropathy; cirrhosis or CKD from chronically elevated central venous pressures); other CHD high-risk features including palliation with prohibitive risk for further single ventricle palliation and cyanotic heart disease with severe AV valve regurgitation and prohibitive operative risk; reactive pulmonary hypertension at risk of fixed irreversible PVR that could preclude heart transplant in the future; neonatal cyanotic CHD with high-risk features; cystic fibrosis with progressive irreversible cardiac dysfunction; dilated cardiomyopathy.

See policy I.A. (chunks 2,6) for full enumerated items

B. Disease severity: Meets one of the staging criteria: age ≥ 18 requires New York Heart Association (NYHA) class III or IV; age < 18 requires American Heart Association (AHA) Stage C or D heart disease. Life expectancy in the absence of cardiopulmonary disease is ≥ 2 years.NYHA III/IV for ≥18; AHA Stage C/D for <18; life expectancy ≥2 years

chunks 6,9,11

C. Contraindications absent: Does not have any of the contraindications listed in I.C.: uncontrolled HIV unless controlled with CD4 >200 cells/mm3 for at least 3 months and on effective ART and no active untreated AIDS-defining infection; absence of chronic wasting or severe malnutrition; inability to adhere to required regimen even with caregiver support; severe hypoplasia of central pulmonary arteries or veins; current ongoing acute allograft rejection or <6 months since primary transplant when retransplantation requested; malignancy with high risk of recurrence or death; acute renal failure with low likelihood of recovery or dialysis dependence; acute liver failure or cirrhosis with portal hypertension unless considered for multi-organ transplant; recent stroke, acute coronary syndrome, or myocardial infarction within 30 days; GFR <30 mL/min/1.73m2 unless multi-organ transplant is planned; septic shock; active extrapulmonary or disseminated infection; active tuberculosis; progressive cognitive impairment; other severe uncontrolled medical conditions expected to limit survival after transplant; active substance use or dependence (including current tobacco, vaping, marijuana use unless prescribed, or IV drug use) without convincing evidence of risk-reduction (exceptions for urgent timelines with commitment to reduce behaviors); history of substance use without documented abstinence (including nicotine replacement) for ≥ 6 months prior to transplant; and cases where lung transplant alone would restore right ventricular function.

chunks 6,8

Specific contraindications listed in Criteria I.C. are exclusions to coverage for heart‑lung transplantation. These include, but are not limited to, active extrapulmonary or disseminated infection, active tuberculosis infection, septic shock, recent stroke, acute coronary syndrome, or myocardial infarction within 30 days, malignancy with high risk of recurrence or death, and glomerular filtration rate < 30 mL/min/1.73m2 unless being considered for multi‑organ transplant. Other exclusionary items include progressive cognitive impairment, severe central pulmonary vessel hypoplasia, ongoing acute allograft rejection or retransplantation requested within six months of the primary transplant, and substance use conditions described in I.C.16 that lack convincing evidence of risk‑reduction.

The policy removed indication I.A.2.d (pulmonary alveolar proteinosis) from the list of approved indications for combined heart‑lung transplantation; this diagnosis is no longer an indication in the updated criteria.

Contraindications that reflect active, uncontrolled conditions or a low likelihood of recovery are considered grounds for denial or deeming transplant not medically necessary. Examples include active extrapulmonary or disseminated infection, septic shock, active tuberculosis, acute renal failure on dialysis with low likelihood of recovery, and acute liver failure or cirrhosis with portal hypertension unless multi‑organ transplant is being considered. Progressive cognitive impairment or other severe uncontrolled medical conditions expected to limit post‑transplant survival also fall into this category.

The policy explicitly removed the previously specified serial blood and urine testing requirements referenced in Criteria I.C.16. The policy no longer mandates those detailed serial testing schedules as part of the substance‑use related evaluation.

Candidate Selection and Listing

Candidate selection

Candidate must meet diagnosis, severity, life expectancy, and absence of contraindications

Diagnosis and indications: See coverage criteria I.A.: age-specific diagnostic lists (adult and pediatric) including congenital heart disease with specified high-risk features, pulmonary vascular disease and primary pulmonary hypertension, cystic fibrosis with progressive cardiac dysfunction, cardiomyopathies, and other listed diagnoses that result in end-stage heart and lung disease.

chunks 2,6

Severity: Meets staging criteria appropriate to age: adults (age ≥18) require NYHA class III or IV; pediatric candidates (age <18) require AHA Stage C or D. Expected life expectancy in absence of disease is ≥2 years.NYHA III/IV for ≥18; AHA Stage C/D for <18; life expectancy ≥2 years

chunks 6,9,11

Contraindications absent:

Contraindications and Exclusion Criteria

The document enumerates absolute and relative contraindications to heart‑lung transplantation that should be assessed during candidate evaluation. Key items include uncontrolled or inadequately controlled HIV unless the candidate meets specific control criteria, active systemic infections including extrapulmonary/disseminated infection and active tuberculosis, septic shock, recent stroke/acute coronary syndrome/MI within 30 days, malignancy with high recurrence risk, acute renal failure with low likelihood of recovery, and acute liver failure or cirrhosis with portal hypertension unless considered for multi‑organ transplant. The list also includes severe hypoplasia of central pulmonary arteries or veins, ongoing acute allograft rejection, progressive cognitive impairment, and conditions related to substance use—both current active use without convincing risk‑reduction evidence and a history without documented ≥ six months abstinence.

Updated criteria call out severe malnutrition and active alcohol or illicit drug use as factors that affect candidacy. The revisions added specific language identifying severe malnutrition in I.C.1.d and reworded substance‑use language in I.C.16 to reflect alcohol or illicit drug use as contraindications when risk‑reduction is not documented.

Pre-Transplant Evaluation Requirements

Prior Authorization

Prior authorization required when policy criteria are met

Prior authorization is required and must confirm that the member meets all enumerated clinical criteria (indications, disease severity, life expectancy, and absence of contraindications) before heart‑lung transplant is approved.

Prior authorization should verify that the candidate meets sections A (indication), B (disease severity including NYHA/AHA staging and life expectancy ≥2 years), and C (no listed contraindications).
Referenced procedure codes (CPT 33930, 33933, 33935 and HCPCS S2152) are listed in the policy and may be referenced during prior authorization review.

Prior Authorization

Follow Health Plan prior authorization process and policy alignment

Submit prior authorization requests in accordance with the Health Plan's coverage determination processes; the clinical policy and applicable Medicare/Medicaid rules must guide authorization decisions.

Ensure requests align with this clinical policy (CP.MP.132) and any applicable plan or regulatory billing rules.

Coding and Billing References

Referenced procedure codesCPT | HCPCS

33930	Donor cardiectomy‑pneumonectomy (including cold preservation).
33933	Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation.
33935	Heart‑lung transplant with recipient cardiectomy‑pneumonectomy.
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.

inv-07: GFR threshold — key numeric threshold referenced for candidate evaluation

GFR thresholdGFR < 30 mL/min/1.73 m2 (contraindication to isolated heart‑lung transplant unless multi‑organ transplant planned)

ContextGFR < 30 is listed among contraindications that may preclude listing for heart‑lung transplant unless part of a planned multi‑organ transplant

Related actionDocument renal function (eGFR) in evaluation and consider multi‑organ transplant pathway when GFR < 30

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required when criteria are met

Obtain prior authorization and verify that the member meets all enumerated clinical criteria (indications, disease severity, life expectancy, and absence of contraindications) before considering heart‑lung transplant medically necessary.

Prior authorization should confirm meeting sections A, B, and C of the policy.
Ensure documentation shows diagnosis consistent with age‑specific indication lists and severity criteria.

Prior Authorization

Follow Health Plan prior‑authorization and coverage processes

Submit prior authorization requests in accordance with the Health Plan's coverage determination processes; determinations must align with this clinical policy and applicable Medicare/Medicaid rules where relevant.

Follow Health Plan administrative policies and benefit documents when requesting authorization.
For Medicare members, review applicable NCDs and LCDs prior to applying policy criteria.

Transplant Center and Administrative Requirements

Note

Center requirements: not specified here

Center‑level requirements are not specified in this portion of the policy; the policy references ISHLT listing criteria and best practice recommendations for evaluation and listing standards.

Note

Centers must follow Health Plan administrative policies and standards

Transplant centers and provider obligations remain subject to Health Plan administrative policies and standards of medical practice; authorization and coverage decisions must conform with those administrative policies and applicable regulatory rules.

Ensure center and provider credentialing and administrative submissions follow Health Plan requirements.
Align post‑transplant care coverage with plan benefits and applicable Medicare/Medicaid determinations.

Post-Transplant Coverage and Global Services

inv-27: global transplant services — HCPCS S2152 describes global procurement/transplant services including pre- and posttransplant days

HCPCS S2152 descriptionS2152 describes solid organ procurement/transplant services (deceased or living donor) including procurement, transplantation, related complications, drugs, supplies, hospitalization with outpatient follow‑up, medical/surgical/diagnostic/emergency/rehabilitative services, and the number of days of pre‑ and posttransplant care in the global definition

ScopeApplies to complete or segmental single organ or combination organ transplants; includes procurement and transplantation services

Coding noteS2152 is referenced alongside CPT codes for donor and recipient procedures; include when billing global transplant services as defined

inv-28: general post-transplant care — Post-transplant coverage should align with plan benefits and applicable Medicare/Medicaid rules

Coverage alignmentPost‑transplant coverage and requirements must align with the member's plan benefits and applicable Medicare/Medicaid NCDs and LCDs

Definitions and Staging

inv-17: NYHA and AHA heart failure staging — NYHA Class I–IV and AHA Stages A–D referenced for severity definitions

NYHA classes (adults)NYHA Class I–IV definitions (Class III or IV required for age ≥18 for listing)

AHA stages (pediatrics)AHA Stages A–D definitions (Stage C or D required for age <18 for listing)

ApplicationPolicy uses NYHA (adults) and AHA stages (pediatrics) to define disease severity thresholds for transplant eligibility

inv-18: Guideline sources — References and guideline sources cited (ISHLT, AHA, others)

ISHLT listing criteria and consensus documentsInternational Society for Heart and Lung Transplantation listing criteria and consensus documents are cited as primary guideline sources informing evaluation and selection

American Heart Association (AHA)

Background and Rationale

Heart‑lung transplantation is indicated for selected patients with simultaneous end‑stage heart and end‑stage lung disease, including diagnoses such as Eisenmenger syndrome, primary pulmonary hypertension, and cystic fibrosis when combined cardiopulmonary failure is irreversible. The procedure is uncommon because of donor availability and has historically shown improved median survival in recent eras (reported improvement from 3.7 years to 6.5 years across cited time periods). ISHLT listing criteria and other specialty guidance inform candidate selection and evaluation.