Blue Cross Blue Shield MA Lung Transplant Coverage

Coverage Criteria for Lung and Lobar Lung Transplantation

Medical Necessity for Lung or Lobar Lung Transplant

Covered when ALL of the following are met

Primary medical necessity: Individual has irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximum medical therapy

From policy: medically necessary for carefully selected individuals

Acceptable etiologies: Includes chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis (both lungs), alpha-1 antitrypsin deficiency, pulmonary hypertension, bronchiectasis, bronchiolitis obliterans, scleroderma, lymphangioleiomyomatosis, eosinophilic granuloma, emphysema, postinflammatory pulmonary fibrosis, sarcoidosis, and related end-stage lung diseases listed in policy

Etiologies listed in policy

Therapy prerequisites: Patient has received maximal medical therapy appropriate to their condition (including oxygen supplementation and surgical options such as lung volume reduction when appropriate) prior to consideration for transplant

Policy requires exhaustion of other therapies before transplant

Contraindications and exclusions: No known active malignancy or untreated systemic infection that would make immunosuppression unsafe; no other irreversible end-stage disease not attributable to lung disease; no systemic disease likely to be exacerbated by immunosuppression; coronary artery disease not amenable to intervention or significant left ventricular dysfunction; no psychosocial conditions or chemical dependence that preclude adherence; not colonized with highly resistant or highly virulent organisms; candidates with recently treated malignancy must have transplant team justification documenting acceptably low risk of recurrence

Policy lists multiple specific exclusionary conditions and requires team assessment for recent malignancy

Lung Retransplantation

Covered when ALL of the following are met

Retransplant criteria: Candidate meets the same selection criteria required for initial lung transplantation (meets medical necessity, therapy prerequisites, and does not have exclusionary conditions)

Policy states retransplantation is medically necessary in patients who meet lung transplant criteria; evidence shows favorable outcomes in selected patients

General coverage stance

Covered when ALL of the following apply:

Primary covered indications: Patient has end-stage pulmonary disease and meets transplant candidate criteria; single, double, lobar, or retransplantation may be considered as clinically appropriate

Evidence summary: lung transplant improves net health outcome; lobar transplant and retransplantation may be appropriate in selected patients

Evidence and outcomes: Sufficient evidence from registries and case series supports improved net health outcome for lung transplantation; lobar transplant data are more limited but suggest possible benefit; retransplantation has moderate-level evidence of posttransplant survival in selected patients

Summary of Evidence in policy

Coverage limits: Transplantation is covered only when the above criteria are met; lung or lobar lung transplantation is considered investigational in situations not meeting specified criteria

Policy exclusion statement

Lung or lobar lung transplantation is considered investigational for any situation that does not meet the policy's specified selection criteria. In other words, when a patient does not satisfy the medical necessity requirements and candidate selection conditions listed in the policy (including contraindications and prerequisites), the procedure is investigational and not supported by this policy.

The excerpted portion of the policy does not enumerate additional explicit exclusions beyond those embedded in the candidate selection and contraindication language. Readers should interpret the policy's investigational statement as applying to all other scenarios not meeting the documented criteria and consult the full policy and referenced guidance for any product-specific or program-specific exclusions.

The policy lists multiple candidate contraindications that render lung or lobar lung transplantation not medically necessary unless specifically justified by the transplant team. Key contraindications include known active malignancy (including metastatic cancer), untreated systemic infection that makes immunosuppression unsafe (including chronic infection), recently treated malignancy with a high risk of recurrence without transplant-team justification, other irreversible end-stage disease not attributable to lung disease, systemic disease likely to be worsened by immunosuppression, coronary artery disease not amenable to revascularization or significant left ventricular dysfunction, psychosocial conditions or chemical dependence that would impair adherence, and colonization with highly resistant or highly virulent organisms.

Patients who do not meet the established transplant candidate criteria or who have the contraindications listed in the policy are implied to be noncovered for lung or lobar lung transplantation. The policy frames coverage around meeting all specified medical necessity criteria; absence of those criteria therefore implies the procedure is investigational or not medically necessary for that individual.

Coding — Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

32851	Lung transplant,single; without cardiopulmonary bypass
32852	Lung_transplant,_single;_with cardiopulmonary bypass
32853	Lung transplant; double (bilateral sequential or en bloc); without cardiopulmonary bypass
32854	Lung transplant_double_(bilateral sequential or en bloc);_with cardiopulmonary bypass

Covered HCPCS CodesHCPCSCovered

S2060

Lobar lung transplantation

ICD-10-PCS Procedure CodesICD-10

OBYCOZO	ICD-10-PCS transplant codes listed in policy (various lung/lobe transplantation procedure codes)
OBYCOZ1	Transplantation of Right Upper Lung Lobe, Syngeneic, Open Approach
OBYDOZO	Transplantation of Right Middle Lung Lobe, Allogeneic, Open Approach
OBYDOZI	Transplantation of Right Middle Lung Lobe, Syngeneic, Open Approach
OBYFOZO	Transplantation of Right Lower Lung Lobe, Allogeneic, Open Approach
OBYHOZI	Transplantation of Lung Lingula, Syngeneic, Open Approach
OBYJOZ1	Transplantation of Left Lower Lung Lobe, Syngeneic, Open Approach
OBYLOZO	Transplantation of Left Lung, Allogeneic, Open Approach
OBYMOZO	Transplantation of Bilateral Lungs, Allogeneic, Open Approach
OBYMOZ1	Transplantation of Bilateral Lungs, Syngeneic, Open Approach

Lung Allocation Score (LAS)

Range0–100

PurposeUsed to prioritize potential lung transplant recipients by predicted survival after transplantation and predicted survival on the waiting list

Applicable age groupCandidates 12 years of age and older are ranked by the Lung Allocation Score; children <12 have separate pediatric priority rules

Provider Actions — Authorization, Documentation, and Prior Authorization

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required for services described in this policy when performed in the inpatient setting. Lack of required precertification/preauthorization may result in denial of payment.

Applies to all products when the procedure is performed inpatient.

Prior Authorization

Prior Authorization and Certification Procedures

Providers must follow the payer’s prior authorization and transplant certification procedures and ensure documentation aligns with transplant center certification requirements and CMS/OPTN guidance. Submit all required prior authorization forms and any supporting clinical documentation to demonstrate that the candidate meets established transplant selection criteria.

Follow OPTN and CMS transplant certification guidance.
Include transplant center certification where applicable.

Candidate Selection and Allocation Criteria

Candidate selection and allocation

Criteria and prioritization for lung transplant candidates

Age and allocation: Potential recipients aged 12 years and older are prioritized using the Lung Allocation Score (LAS, 0–100); children younger than 12 receive pediatric priority rulesLAS 0-100

Policy describes LAS and pediatric priority

Clinical severity and eligibility: Candidate has end-stage lung disease despite maximal medical therapy and meets indication(s) for transplant based on disease etiology and severity

Candidates must have exhausted other treatments (including oxygen and surgical options when appropriate)

Center and regulatory alignment: Allocation and candidate selection follow LAS, geography, blood type, and applicable OPTN/UNOS and CMS policies; transplant centers must follow referenced certification and selection guidance

Contraindications to Transplant

Contraindications that preclude lung or lobar lung transplantation include: known active malignancy (including metastatic cancer); untreated systemic infection making immunosuppression unsafe (including chronic infections); recently treated malignancy with high risk of recurrence unless the transplant team provides justification; other irreversible end-stage disease not due to lung disease; systemic disease likely to be exacerbated by immunosuppression; coronary artery disease not amenable to intervention or significant LV dysfunction; psychosocial conditions or chemical dependence affecting adherence; and colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.

Evaluation Requirements Prior to Transplant

Documentation Required

Evaluation requirements: malignancy risk and routine pretransplant assessments

The transplant team must assess the risk of malignancy recurrence and provide a supporting statement when applicable; perform routine pretransplant infectious disease testing and other standard pretransplant evaluations per the policy and referenced public health guidance.

Assess and document malignancy recurrence risk and provide transplant team justification if recently treated malignancy is present.
Perform routine infectious disease testing per Public Health Service and guideline recommendations (HIV, HBV, HCV).

Note

Center and transplant team requirements for candidate assessment

Transplant team assessment of malignancy cases and overall candidate suitability is required; transplant centers should adhere to certification/accreditation standards and referenced selection documents.

Document transplant team determination of candidate suitability, especially for patients with prior cancer or other exclusionary conditions.

Post-Transplant Care and Coverage Considerations

Post‑transplant care and monitoring

ImmunosuppressionTransplant recipients require lifelong immunosuppression to prevent rejection

Monitoring needsOngoing monitoring for complications including infection and malignancy is required posttransplant

Outcome contextPosttransplant outcomes and survival are discussed in evidence summaries and inform follow-up care

Post‑transplant care and follow‑up

Coverage approachCoverage for post‑transplant care follows clinical appropriateness and standard posttransplant care plans per cited guidelines and CMS/OPTN requirements

Outcomes consideredKey considerations include overall survival, change in disease status, and treatment‑related morbidity and mortality

Background and Context

Lung transplantation (single, double, or lobar) is an established treatment option for carefully selected patients with irreversible, progressively disabling end-stage pulmonary disease who have failed maximal medical therapy. Evidence from registry and case series data supports improved net health outcomes for appropriately selected recipients; lobar transplantation has more limited data but may be an option when whole organs are unavailable, and retransplantation can be considered for patients who meet selection criteria. Recipients require lifelong immunosuppression and are prioritized for organs in part by the Lung Allocation Score (0–100) and established allocation rules.

Definitions

Lobar transplant — definition and donor types

DefinitionLobar transplant: a lobe of the donor's lung is excised, sized for the recipient's thoracic dimensions, and transplanted (rather than a whole lung)

Donor typesDonors for lobar transplant have primarily been living‑related donors (one lobe from each of two donors for bilateral needs); cadaveric (deceased donor) lobes have also been used

Use caseMay be performed when whole‑lung organs are unavailable or to match recipient thoracic size requirements

Lung Allocation Score (LAS)

Score range0–100

UsePrioritizes potential recipients aged 12 years and older based on predicted posttransplant survival and survival on the waiting list