Heart/Lung Transplant
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Medical necessity and coverage guidance for combined heart and lung transplantation and retransplantation for selected individuals with end-stage cardiac and pulmonary disease; applies to Capital BlueCross-administered products with benefit variations noted.
No material clinical or coverage changes in this revision.
Coverage Criteria for Heart/Lung Transplant
Medically necessary indications and retransplantation
Covered when ALL of the following are met for carefully selected individuals:
Based on list in policy (see policy indications).
Policy permits retransplantation when transplant criteria are met.
Organ allocation and priority criteria
Allocation and prioritization considerations:
Includes pediatric-specific considerations and severity markers (ventilation, IV inotropes, mechanical circulatory support, pulmonary pressures).
General coverage mapping
Covered when medically necessary:
This section maps covered procedure codes to qualifying diagnosis codes; clinical eligibility must be demonstrated per other policy criteria.
When the listed clinical indications are not met, heart/lung transplantation is considered investigational. The policy states that combined heart and lung transplant may be considered medically necessary only for carefully selected individuals with specified end-stage cardiopulmonary conditions; procedures performed outside those indications are investigational due to insufficient evidence of benefit. Candidates with contraindications described in the policy may also be excluded from coverage if the contraindication makes transplantation unsafe or inappropriate.
The policy excerpt provided does not enumerate additional explicit exclusions beyond the investigational statement; however, the policy history documents that an investigational statement and related literature were added during prior reviews. The history shows administrative and consensus reviews with updates to background, definitions, references, and coding, but no further specific excluded indications are listed in this excerpt.
The policy specifies that heart/lung transplantation is investigational (not medically necessary) for indications other than the defined end-stage cardiopulmonary conditions listed in the policy (for example, irreversible primary pulmonary hypertension with heart failure, severe pulmonary fibrosis with severe heart failure, Eisenmenger complex, cystic fibrosis with severe heart failure, COPD/emphysema with severe heart failure, or pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure).
The excerpt does not contain a separate, explicit list of 'not medically necessary' conditions beyond the general investigational statement. Policy history notes prior additions of investigational language and literature, but no distinct not-medically-necessary items are presented in this segment.
Candidate Selection and Eligibility
Candidate clinical criteria
Candidate selection focuses on end-stage cardiopulmonary disease with assessment of disease severity and transplant candidacy:
See policy list of indications.
Severity markers reflect UNOS/OPTN factors referenced in the policy.
Reference-based candidate selection
References and guidance informing candidate selection
Policy references international society reports, OPTN/UNOS policies, and transplant registry literature to inform candidate selection.
Contraindications and Denial-Risk Conditions
Contraindications that may lead to denial
Contraindications listed in the policy may lead to denial of coverage for heart/lung transplantation if present. Examples include active or recent malignancy, untreated systemic infection, non–cardio/pulmonary irreversible end‑stage disease, systemic disease worsened by immunosuppression, and psychosocial or chemical‑dependency issues that impair adherence.
- Known current malignancy, including metastatic cancer
- Recent malignancy with high risk of recurrence
- Untreated systemic infection (including chronic infection) that makes immunosuppression unsafe
- Other irreversible end‑stage disease not attributed to heart or lung disease
- History of cancer with moderate risk of recurrence
- Systemic disease that could be exacerbated by immunosuppression
- Psychosocial conditions or chemical dependency affecting ability to adhere to therapy
The policy identifies the following contraindications that may preclude approval for combined heart/lung transplantation and could lead to denial if present: known current malignancy (including metastatic cancer); recent malignancy with high risk of recurrence; untreated systemic infection (including chronic infection) that would make immunosuppression unsafe; other irreversible end-stage disease not attributable to heart or lung disease; history of cancer with moderate risk of recurrence; systemic disease likely to be worsened by immunosuppression; and psycho‑social conditions or chemical dependency that impair the ability to adhere to therapy.
Not specified in this excerpt.
Provider Actions, Documentation, and Billing Guidance
Prior authorization required
Prior authorization is required for heart/lung transplantation services listed in the coding section and is subject to member benefits and medical necessity review.
Preference for isolated transplant when feasible
When medically appropriate, isolated cardiac or pulmonary transplantation is preferred to combined heart/lung transplantation if medical or surgical management (other than organ transplantation) is available.
No action specified
No specific provider action text provided in the policy excerpt for this inventory item.
Required clinical documentation
Clinical documentation submitted for authorization must demonstrate medical urgency and severity per UNOS/OPTN criteria, for example dependence on continuous mechanical ventilation, infusion of IV inotropes, or dependence on mechanical circulatory support, and pulmonary severity measures such as pulmonary artery pressures or pulmonary vascular resistance.
- Evidence of ventilation, IV inotropes, or mechanical circulatory support
- Pulmonary artery pressures or elevated pulmonary vascular resistance
Required diagnosis documentation
Clinical documentation must support one of the listed ICD‑10‑CM diagnoses when requesting heart-lung transplant services (examples include E84.0/E84.8 for cystic fibrosis; the I27.* pulmonary hypertension codes; I50.* heart failure codes; J43.*, J44.*, J84.10; and T86.32 for transplant failure).
- E84.0, E84.8 (cystic fibrosis)
- I27.* (primary and secondary pulmonary hypertension, Eisenmenger's syndrome, cor pulmonale, etc.)
- I50.* (heart failure codes including I50.84 end‑stage heart failure)
- J43.*, J44.*, J84.10
- T86.32 (heart‑lung transplant failure)
Diagnosis‑documentation mismatch may trigger denial
If the clinical record does not document one of the policy‑listed diagnosis codes (for example E84.*, I27.*, I50.*) to support medical necessity, the request may be denied.
Coding: Procedure and Diagnosis Codes
| E84.0 | Cystic fibrosis with pulmonary manifestations |
| E84.8 | Cystic fibrosis with other manifestations |
| I27.0 | Primary pulmonary hypertension |
| I27.1 | Kyphoscoliosis heart disease |
| 33940 | Procedure code listed in policy |
| 33944 | Procedure code listed as equivalent to 33940 + S2060 |
| 33945 | Procedure code listed as equivalent to 33940 + S2061 |
| 33930 | Procedure code referenced in combination with 33940 |
| 33933 | Procedure code referenced in combination with 33940 |
| 33935 | Procedure code referenced in combination with 33940 |
| S2060 | HCPCS code referenced in combination |
| S2061 | HCPCS code referenced in combination |
| S2152 | HCPCS code referenced in combination |
| E84.0 | Cystic fibrosis with pulmonary manifestations |
| E84.8 | Cystic fibrosis with other manifestations |
| I27.0 | Primary pulmonary hypertension |
| I27.1 | Kyphoscoliosis heart disease |
| I27.21 | Secondary pulmonary arterial hypertension |
| I27.22 | Pulmonary hypertension due to left heart disease |
| I27.23 | Pulmonary hypertension due to lung diseases and hypoxia |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I27.29 | Other secondary pulmonary hypertension |
| I27.83 | Eisenmenger's syndrome |
Pre-Transplant Evaluation Requirements
Evaluation must document UNOS/OPTN urgency and severity measures
Evaluation should document UNOS/OPTN‑based urgency and severity measures, including respiratory support (ventilation), IV inotropic therapy, dependence on mechanical circulatory support, and pulmonary hemodynamics such as pulmonary artery pressures and pulmonary vascular resistance.
- Continuous mechanical ventilation
- Infusion of IV inotropes
- Dependency on mechanical circulatory support (e.g., VAD, ECMO)
- Pulmonary artery pressures or elevated pulmonary vascular resistance
Evaluation details referenced but not specified
The excerpt does not specify additional explicit pre‑approval workup steps; referenced literature and guidelines (ISHLT, OPTN/UNOS) inform evaluation but detailed requirements are not provided here.
Transplant Center and Program Requirements
Provide transplant services at appropriate centers (BDCT referenced)
Transplants should be performed at appropriate, experienced centers; the policy cross‑references Blue Distinction Centers for Transplant and related Capital BlueCross transplant policies.
- See Blue Distinction Centers for Transplant (BDCT) program references
- Refer to related Capital BlueCross transplant policies (MP 9.007, MP 9.015, MP 1.026)
OPTN/UNOS/CMS center policies referenced; no specific accreditation stated
The policy cites OPTN/UNOS and CMS transplant center policies as references but does not state specific accreditation, volume, or numeric center requirements in this excerpt.
Post-Transplant Coverage and Retransplantation
Background and Clinical Context
Combined heart/lung transplantation is a coordinated operative procedure that transplants a donor heart and one or both lungs from a single cadaver donor as a unit. The operation involves procurement of a donor heart/lung block, excision of the recipient’s native heart and lung(s), and implantation of the donor organs. Recipients require lifelong immunosuppression and face procedure-related risks including allograft rejection and chronic airway or parenchymal complications, which are considered in candidate selection and post-transplant management.
Definitions
Coding References and Source Citations
| 33940 | Procedure code listed in policy |
| 33944 | Procedure code listed as equivalent to 33940 + S2060 |
| 33945 | Procedure code listed as equivalent to 33940 + S2061 |
| 33930 | Procedure code referenced in combination with 33940 |
| 33933 | Procedure code referenced in combination with 33940 |
| 33935 | Procedure code referenced in combination with 33940 |
| S2060 | HCPCS code referenced in combination |
| S2061 | HCPCS code referenced in combination |
| S2152 | HCPCS code referenced in combination |
| E84.0 | Cystic fibrosis with pulmonary manifestations |
| E84.8 | Cystic fibrosis with other manifestations |
| I27.0 | Primary pulmonary hypertension |
| I27.1 | Kyphoscoliosis heart disease |
| I27.21 | Secondary pulmonary arterial hypertension |
| I27.22 | Pulmonary hypertension due to left heart disease |
| I27.23 | Pulmonary hypertension due to lung diseases and hypoxia |
| I27.24 | Chronic thromboembolic pulmonary hypertension |
| I27.29 | Other secondary pulmonary hypertension |
| I27.83 | Eisenmenger's syndrome |
Policy Revision History
Minor review: added investigational statement and related literature; revised document history entry.
Policy effective date updated to 2026-02-01 per document header dates.
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