CurrentAmbetter NevadaPolicy CP.MP.132

Clinical Policy: Heart-Lung Transplant

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Clinical policy governing medical necessity and coverage guidance for heart-lung transplant procedures and associated decision-making for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyHeart-Lung Transplant

Policy CodePolicy CP.MP.132

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member benefit coverage and obtain prior authorization per the member's plan documents before proceeding with transplant-related services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IncludedReferences

NotedCMS/state alignment

2018Material ownership year

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CurrentAmbetter NevadaPolicy CP.MP.132

Clinical Policy: Heart-Lung Transplant

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Clinical policy governing medical necessity and coverage guidance for heart-lung transplant procedures and associated decision-making for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyHeart-Lung Transplant

Policy CodePolicy CP.MP.132

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member benefit coverage and obtain prior authorization per the member's plan documents before proceeding with transplant-related services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IncludedReferences

NotedCMS/state alignment

2018Material ownership year

Coverage Criteria

Coverage for heart-lung transplant services is subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and to applicable state and federal requirements. Where state Medicaid provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. The Health Plan reserves the right to change, amend, or withdraw this clinical policy; applicable laws and regulations govern in the event of any discrepancy.

Provider Actions & Authorization

Prior Authorization

Prior authorization guidance — verify benefits and PA requirements

This clinical policy is used to assist in making coverage decisions and administering benefits; providers must verify benefit coverage and prior authorization requirements per the member's plan documents and administrative procedures before delivering services.

Note

Administrative steps before transplant services

Providers should follow any required administrative steps in the member's plan (such as submitting prior authorization requests) and confirm coverage specifics with the payer prior to scheduling transplant-related services.

Confirm member eligibility and benefit limits
Submit prior authorization requests when required by the plan
Follow plan administrative procedures for notifications and approvals

Documentation Required

Provider responsibility — exercise professional judgment

Providers remain responsible for exercising professional medical judgment and for the medical advice and treatment of members; coverage determinations are guided by the medical necessity criteria in this policy but do not replace clinical judgment.

Apply professional judgment to individual patient care decisions
Recognize that this policy does not dictate clinical practice or recommend specific treatments

Denial Risk

Coverage decisions subject to plan terms, exclusions, and law

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and to applicable state and federal requirements; where state Medicaid provisions conflict with this policy, the state Medicaid provisions prevail.

Verify contract terms, exclusions, limitations, and applicable legal/regulatory requirements
Compliance with state Medicaid manual provisions supersedes conflicting policy wording

Background and Guideline Context

This policy references contemporary guidance and consensus statements, including International Society for Heart and Lung Transplantation (ISHLT) materials, as part of the evidence base informing selection and referral for heart-lung transplant. The policy is intended to provide medical necessity guidance and does not dictate clinical care; providers must continue to exercise professional judgment in diagnosis, referral, and treatment decisions.

Providers are responsible for verifying benefit coverage and prior authorization requirements per the member's plan documents and applicable regulatory requirements. This clinical policy does not constitute medical advice and is not a substitute for individualized clinical assessment.

Definitions & Clinical Policy Notes

Clinical policy — key definitions and guidance

DefinitionClinical policy: Medical necessity guidance; this policy does not constitute medical advice and providers must exercise professional medical judgment.

ScopeApplies to heart-lung transplant coverage determinations for Ambetter Nevada members and is subject to plan terms, conditions, exclusions and limitations.

Provider responsibilityProviders are responsible for medical advice and treatment decisions and must verify benefit coverage and prior authorization requirements per the member's plan documents.

Legal precedenceIf state Medicaid provisions conflict with this policy, state Medicaid coverage provisions take precedence; legal and regulatory requirements govern discrepancies.

Policy ownershipThis clinical policy is the property of the Health Plan and may be changed, amended or withdrawn at any time.

Post-Transplant Coverage Considerations

Post‑transplant coverage — Medicare/Medicaid alignment

Medicare consistencyEnsure consistency with Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles; review applicable NCDs/LCDs prior to applying this policy.

CMS referenceRefer to the CMS website (http://www.cms.gov) for additional information on NCDs, LCDs, and coverage articles.

Medicaid precedenceFor Medicaid members, when state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence; consult the state Medicaid manual.

Applicability noteReview NCDs/LCDs in conjunction with this policy to ensure regulatory compliance for Medicare beneficiaries before applying criteria.

Policy Summary

PayerAmbetter Nevada

PolicyHeart-Lung Transplant

Policy CodePolicy CP.MP.132

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member benefit coverage and obtain prior authorization per the member's plan documents before proceeding with transplant-related services.

SourceLink

On This Page

Clinical Policy: Heart-Lung Transplant

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Clinical Policy: Heart-Lung Transplant

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Coverage Criteria

Provider Actions & Authorization

Background and Guideline Context

Definitions & Clinical Policy Notes

Center Requirements

Post-Transplant Coverage Considerations