CurrentAmbetter GeorgiaPolicy CP.MP.57

Clinical Policy: Lung Transplantation

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Defines medical necessity criteria, candidate evaluation, contraindications, and coding for lung transplantation for Ambetter Georgia members (non-Medicare noted in revisions). Applies to providers submitting transplant-related requests and claims.

Policy Summary

PayerAmbetter Georgia

PolicyClinical Policy: Lung Transplantation

Policy CodePolicy CP.MP.57

Change TypeRevised criteria and codingclarified abstinence and GFR thresholds

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for lung transplantation services and document required abstinence and maximal medical therapy efforts.

SourceLink

POLICY UPDATE CHANGES

Updated adult and pediatric criteria to align with ISHLT 2021 consensus and subsequent revisions, including changes to substance use, nicotine/tobacco abstinence, and pediatric indication for alpha-1 antitrypsin deficiency.

Glomerular filtration rate threshold in Criteria I.C.2. was changed several times (noted changes between <30 and <40 mL/min/1.73m2).

Added CPT codes 32850, 32855, and 32856 to the policy coding list.

Nicotine and tobacco abstinence contraindication clarified.

Added a note to refer to MC.CP.MP.57 for Medicare criteria and specified 'non-Medicare' health plans in Policy/Criteria I.

ISHLT 2021Guideline alignment referenced

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CurrentAmbetter GeorgiaPolicy CP.MP.57

Clinical Policy: Lung Transplantation

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Policy Summary

PayerAmbetter Georgia

PolicyClinical Policy: Lung Transplantation

Policy CodePolicy CP.MP.57

Change TypeRevised criteria and codingclarified abstinence and GFR thresholds

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for lung transplantation services and document required abstinence and maximal medical therapy efforts.

SourceLink

POLICY UPDATE CHANGES

Glomerular filtration rate threshold in Criteria I.C.2. was changed several times (noted changes between <30 and <40 mL/min/1.73m2).

Added CPT codes 32850, 32855, and 32856 to the policy coding list.

Nicotine and tobacco abstinence contraindication clarified.

Added a note to refer to MC.CP.MP.57 for Medicare criteria and specified 'non-Medicare' health plans in Policy/Criteria I.

ISHLT 2021Guideline alignment referenced

Coverage Criteria for Lung Transplantation

Initial candidate selection — covered candidate selection criteria and contraindications

Covered when ALL of the following candidate selection criteria are met (policy aligns with ISHLT 2021 consensus and subsequent revisions):

I. General candidacy: End-stage lung disease refractory to maximal medical therapy (including pulmonary rehabilitation when applicable) and, when appropriate, refractory to surgical therapy; patient must have a comorbidity profile acceptable for transplant and a reasonable chance of benefiting from transplantation.

Reflects additions in revisions noting pulmonary rehab and 'or surgical therapy'

II. Organ-specific physiologic thresholds and function

A. Pulmonary function: Where applicable, FEV1 thresholds updated in revisions (e.g., criterion updated from FEV1 <25% to FEV1 <30% for specified indications).FEV1 < 30% (per revised criterion)
B. Renal function: Adequate renal function is required; glomerular filtration rate threshold has been updated in revision history and applied in candidacy evaluation.GFR threshold per policy (revisions changed between <30 and <40 mL/min/1.73m2; see policy for final numeric value)

III. Substance use and psychosocial considerations: Active substance use or dependence is addressed explicitly; documentation of abstinence or a demonstrated commitment to reducing substance use behaviors is required. Marijuana prescribed by a licensed practitioner is excluded from the abstinence prohibition per revisions. Urgent transplant timelines may accept a documented commitment to reduce use.Documented abstinence or documented commitment to reduce substance use behaviors as specified

See Criteria I.C.13 and I.C.14 revisions

IV. Adherence and support: Ability to adhere to the regimen necessary to preserve the transplant is required; inability to adhere even with caregiver support is listed as a contraindication/exclusion.

Replaced former contraindications wording to focus on adherence (see revision history)

V. Special populations and other expanded criteria: Policy includes expanded qualifying criteria for certain populations (for example, qualifying criteria for HIV-positive members and pediatric indications such as alpha-1 antitrypsin deficiency).

See Criteria I.C.9 expansion and pediatric indication additions in revisions

The policy lists inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support as a contraindication to lung transplantation. This replaced prior wording that referenced severely limited functional status or past/nonadherence and is cited in multiple revision notes describing the change to candidate exclusions and contraindications.

The document also expands substance-use related exclusions: active substance use or dependence is addressed in the criteria and tied to required abstinence/documentation; the policy additions and clarifications (including exclusion exceptions for prescribed marijuana and required commitments when urgent transplant timelines exist) are documented in the revision history.

Patients who demonstrate an inability to adhere to medical therapy or to the post-transplant regimen are identified in the policy as inappropriate candidates for transplant. The revision history records replacement of earlier language about poor rehabilitation potential and nonadherence with the current adherence-focused contraindication.

The policy requires documentation related to substance use: candidates must meet the updated abstinence/documentation requirements or, when applicable, demonstrate a documented commitment to reduce substance use behaviors. The policy clarifies nicotine/tobacco abstinence and specifically notes that marijuana prescribed by a licensed practitioner may be excluded from the abstinence prohibition while maintaining documentation expectations when urgent timelines exist.

Candidate Criteria (Summary and Details)

Candidate criteria (summary)

Candidate criteria summary — adult and pediatric candidate criteria aligned with ISHLT consensus, including disease-specific thresholds and special population considerations:

A. Disease-refractory requirement: End-stage lung disease refractory to maximal medical therapy and, when applicable, to surgical therapy; maximal medical therapy includes pulmonary rehabilitation when appropriate.

Added 'or surgical therapy' and clarified pulmonary rehab in revisions

B. Physiologic thresholds (examples)

1. Pulmonary function: FEV1 threshold for specific criteria was updated from <25% to <30% in revisions.FEV1 < 30%
See I.D.2.a.1. revision
2. Renal function:

Contraindications

Contraindications explicitly include inability to adhere to the post‑transplant regimen even with caregiver support. This language replaced prior contraindications related to severely limited functional status and poor rehabilitation potential.

The policy further lists active substance use or dependence without required abstinence/documentation among exclusionary conditions and adds related items such as chronic wasting or severe malnutrition in the revision updates.

Evaluation and Pre-Listing Requirements

Step Therapy

Require trial of maximal medical therapy (including pulmonary rehab) before listing

Maximal medical therapy, including pulmonary rehabilitation when applicable, must be attempted prior to transplant listing; document attempts and responses in the evaluation records.

Policy I: members must have failed maximal medical (including pulmonary rehabilitation, as applicable) or surgical therapy before transplant consideration.
Revision history notes explicitly added: "medical therapy includes pulmonary rehab when applicable."

Provider Actions, Documentation, and Operational Notes

Billing Rule

Prior authorization required; new CPT codes added

Prior authorization is required by the Health Plan for lung transplantation services. The policy's coding list was updated to add CPT codes 32850, 32855, and 32856, which should be included in authorization and billing submissions.

Added CPT codes: 32850, 32855, 32856 (policy revision notes).
Submit prior authorization requests consistent with Health Plan requirements for lung transplant services.

Step Therapy

Requirement: try maximal medical therapy (including pulmonary rehab) before listing

Maximal medical therapy — explicitly including pulmonary rehabilitation when applicable — must be attempted prior to transplant listing as a documented step in the evaluation process.

Document attempts at maximal medical therapy and pulmonary rehabilitation where applicable before listing.

Coding and Claiming

Added CPT CodesCPT

32850	Added CPT code (description as listed in policy)
32855	Added CPT code (description as listed in policy)
32856	Added CPT code (description as listed in policy)

inv-05: Glomerular filtration rate (GFR) — < 30 mL/min/1.73m2 (updated from <40 and changed in revisions)

Glomerular filtration rate (GFR) thresholdGFR < 30 mL/min/1.73m2 (policy updated from <40 mL/min/1.73m2 in prior revisions)

Where appliedUsed as an eligibility threshold in Criteria I.C.2. for candidate evaluation

Revision historyOperational threshold changed between <30 and <40 mL/min/1.73m2 across 2024–2025 updates; current policy reflects <30 mL/min/1.73m2

inv-06: FEV1 threshold (one criterion) — FEV1 < 30% (updated from <25%)

FEV1 thresholdFEV1 < 30% (updated from <25%)

Criteria locationApplied in Criteria I.D.2.a.1. as a disease-specific physiologic threshold for candidate selection

Definitions and Scope Notes

inv-12: non-Medicare — Non-Medicare health plans

DefinitionNon-Medicare health plans

Policy context'Non-Medicare' was added to health plans in Policy/Criteria I to distinguish from Medicare criteria (see MC.CP.MP.57)

Cross-referenceRefer to MC.CP.MP.57 for Medicare-specific criteria; this policy applies to non-Medicare members

Post-Transplant Coverage Considerations

inv-17: post-transplant medical management (general) — Policy references need for adherence to regimen necessary to preserve the transplant; post-transplant coverage specifics not included in ...

Post-transplant adherence importancePolicy references the need for adherence to the regimen necessary to preserve the transplant

Coverage specificsPolicy states post-transplant coverage specifics are not included in this policy window

Provider implicationAbility to adhere to post-transplant regimen is a candidate selection consideration and contraindication if not met, even with caregiver support

Center and Program Requirements

Note

Center requirements not specified in this window — see full policy

The policy text in this window does not specify center accreditation, case-volume, or other explicit transplant center requirements; providers should refer to the full policy for any center-specific expectations.

Refer to the full policy (and related Medicare policy MC.CP.MP.57 if applicable) for any center-level requirements not included in this excerpt.

Background and Guideline Alignment

This policy aligns candidate selection and contraindication language with ISHLT guidance and documents iterative revisions from 2021–2026 that updated adult and pediatric criteria, substance‑use rules, and operational thresholds. Revision notes state the policy was updated to reflect ISHLT 2021 consensus and subsequent clarifications.

Revisions recorded in the document include: replacement of older contraindication language with an adherence‑focused contraindication, clarification of nicotine/tobacco abstinence rules, addition of pediatric indication for alpha‑1 antitrypsin deficiency, and multiple operational updates to candidate thresholds and exclusions. These background notes establish that the policy’s selection criteria and exclusions are intended to be consistent with specialty guidance and were revised accordingly.