Transplantation Services (Organ and Stem Cell Transplantation)
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Defines medical necessity, prior authorization, covered organ and stem cell transplant types, and requirements for transplant evaluation and facility contracting for Baylor Scott & White Health Plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Approval criteria
Covered when ALL of the following are met
Applies to listed organs and stem cells per policy
Medicare NCD criteria
Medicare NCD-aligned coverage for specific organs
See specific NCD references in policy; kidney transplantation has no NCD but is a Medicare Part A/B benefit.
Transplantation is not medically necessary when it occurs outside the policy’s required process. Specifically, transplantation that occurs without following the required prior-authorization and evaluation steps or that is performed in a non-contracted transplant center will be considered not medically necessary.
Transplantation of an organ or organ-pair not listed in this policy is not medically necessary unless prior approval has been obtained. Transplantation involving a non-human organ is also excluded from coverage.
Prior authorization and the sequential evaluation steps are required before a transplant will be approved. If those steps are not followed — for example, if the prior authorization request and the transplant center evaluation and recommendation are not submitted by an applicable contracted specialist and reviewed by BSWHP — the transplant is not medically necessary.
BSWHP will work with the referring specialist to identify a qualified contracted transplant center and requires that the patient undergo a complete evaluation at that center with the center’s recommendation submitted for listing and procedure approval. Failure to obtain the identified/approved contracted center’s evaluation and recommendation prior to proceeding will result in non-coverage.
Coding
| 32850 | Donor pneumonectomy |
| 32851-32854 | Lung transplant |
| 32855 | Backbench preparation of donor lung |
| 32856 | Backbench preparation of donor lung |
| 33930 | Donor cardiectomy-pneumonectomy |
| 33933 | Backbench standard preparation of cadaver donor heart/lung allograft |
| 33935 | Heart-lung transplant with recipient cardiectomy-pneumonectomy |
| 33940 | Donor cardiectomy |
| 33944 | Backbench standard preparation of cadaver donor heart |
| 33945 | Heart transplant with or without recipient cardiectomy |
Provider Actions & Prior Authorization
Prior authorization required
Prior authorization is required for transplantation services; the request must be submitted by an applicable contracted specialist to BSWHP and include the indication for the proposed transplant and the suitability of the patient as a candidate recipient.
Contracted transplant center identification
BSWHP will work with the referring specialist to identify a qualified transplant center that is contracted in the BSWHP network for the indicated organ(s) prior to evaluation and approval.
Required submission and documentation
The prior authorization request for transplant evaluation must be submitted by an applicable contracted specialist to BSWHP and must detail the indication for the proposed transplant and the patient’s suitability; the transplant center’s evaluation and recommendation must be submitted to BSWHP for listing and procedure approval.
Denial risk if steps or contracted center not used
Transplantation is not considered medically necessary if the required prior-authorization and evaluation steps are not followed or if the transplant occurs in a non-contracted center.
Candidate Evaluation Criteria
Candidate evaluation steps
To be considered for approval:
These are sequential requirements that must be satisfied prior to approval/listing.
Evaluation Requirements
Complete transplant evaluation and submit center recommendation
The patient must complete a transplant evaluation at the specified (BSWHP-identified or approved) transplant center and the center’s recommendation for listing and procedure approval must be submitted to BSWHP for review and coverage determination.
Contraindications
Contraindications include situations where there is significant organ system failure of organ(s) not to be transplanted that will not reverse after transplantation of the new organ(s). Such irreversible, non-transplanted organ system failure is listed as a policy exclusion and will preclude coverage.
Claims for transplantation should be evaluated for these contraindications as part of the required pre-transplant evaluation; if irreversible failure of another organ system is present and will persist despite transplant, the procedure is considered not medically necessary.
Transplant Center Requirements
Transplant facility requirements
The transplant must occur at a contracted or otherwise qualified transplant center identified or approved by BSWHP; when Medicare NCDs apply, a Medicare‑approved facility is required per the NCD.
Post-Transplant Coverage
Definitions
Background
Organ transplantation is indicated when the function of a critical organ deteriorates to the point that it is no longer, or will no longer be, adequate to support life. Transplant recipients require intensive, long-term follow-up and multidisciplinary care after the procedure.
Because candidate selection and post-operative management are complex, BSWHP requires a documented transplant evaluation and recommendation from a qualified transplant center prior to listing and procedure approval; this ensures appropriate selection of candidates and coordination of the extensive follow-up care needed after transplantation.
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