CurrentBaylor Scott & White Health PlanPolicy 129

Transplantation Services (Organ and Stem Cell Transplantation)

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.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyTransplantation Services (Organ and Stem Cell Transplantation)

Policy CodePolicy 129

Change TypeNo material change

Effective DateJun 1, 2026

Next Review DateMay 28, 2027

Key ActionSubmit prior authorization for transplant evaluation by a contracted specialist including the transplant center evaluation and recommendation for listing and procedure approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior authorization for transplants

MultipleCovered organs listed

Contracted centerLocation requirement

CoveredDonor costs

NCD referencesMedicare NCDs referenced

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Coverage Criteria

Approval criteria

Covered when ALL of the following are met

Core coverage criteria: 1) Prior authorization request for transplant evaluation submitted by an applicable contracted specialist to BSWHP that details the indication for the proposed transplant and the suitability of the patient as a candidate recipient; 2) BSWHP identifies a qualified contracted transplant center for the indicated organ(s); 3) The patient completes transplant evaluation at the specified transplant center and the center's recommendation for potential listing and procedure approval is submitted to BSWHP; 4) BSWHP reviews the evaluation and recommendation and renders a coverage determination.

Applies to listed organs and stem cells per policy

Medicare NCD criteria

Medicare NCD-aligned coverage for specific organs

NCD-based coverage: When an applicable Medicare National Coverage Determination (NCD) or Local Coverage Determination (LCD) exists (for example: NCD 260.9 Heart Transplants; NCD 260.3 Pancreas Transplants; NCD 260.3.1 Islet Cell Transplantation in the Context of a Clinical Trial; NCD 260.1 Adult Liver Transplantation; NCD 260.5 Intestinal and Multi-Visceral Transplantation; NCD 260.2 Pediatric Liver Transplantation; NCD 110.23 Stem Cell Transplantation), coverage decisions may follow those NCD/LCD criteria and/or require that the procedure occur in a Medicare‑approved facility per the NCD.

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

Covered CPT CodesCPTCovered

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

1–10 of 35

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ICD-10 applicability

ICD-10 applicabilityNone — policy states an inclusive list of diagnosis codes may not be presented due to wide range and changes

ReasonWide range of applicable diagnosis codes and potential code changes make an exhaustive inclusive list impractical

Implication for billingInclusion of a code in guidance does not guarantee reimbursement; member must meet policy clinical criteria

Provider Actions & Prior Authorization

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.

Step Therapy

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.

Documentation Required

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

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:

Evaluation and referral: 1) Prior authorization submitted by an applicable contracted specialist to BSWHP that details the indication and suitability of the patient as a transplant candidate; 2) Identification by BSWHP, working with the referring specialist, of a qualified contracted transplant center for the indicated organ(s); 3) Completion of transplant evaluation at the specified transplant center with the center's recommendation for potential listing and procedure approval submitted to BSWHP; 4) BSWHP review of the evaluation and recommendation and issuance of a coverage determination.

These are sequential requirements that must be satisfied prior to approval/listing.

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.

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.

OpenPayer

Transplantation Services (Organ and Stem Cell Transplantation)

Coverage Criteria

Coding

Provider Actions & Prior Authorization

Candidate Evaluation Criteria

Evaluation Requirements

Contraindications

Transplant Center Requirements

Post-Transplant Coverage

Definitions

Background