CurrentCentenePolicy CP.MP.57

Lung Transplantation

Defines medical necessity criteria for lung transplantation for non-Medicare Centene-affiliated health plans (members/enrollees with chronic end-stage lung disease) including eligibility disease-specific thresholds, absolute contraindications, and references to Medicare-specific policy. Also lists relevant CPT/HCPCS codes for transplantation procedures and donor procurement.

Policy Summary

PayerCentene

PolicyLung Transplantation

Policy CodePolicy CP.MP.57

Change TypeRevisedAddedClarified

Effective Date

Next Review Date

Key ActionProviders must document failure of maximal medical or surgical therapy and submit objective disease-specific data to support transplant requests.

SourceLink

POLICY UPDATE CHANGES

Updated glomerular filtration rate contraindication to GFR < 40 mL/min/1.73m2 (from prior values of <30 or <40 in earlier revisions) and expanded HIV-related qualifying criteria including CD4 count timing and added chronic wasting/malnutrition exclusion.

Added CPT codes 32850, 32855, and 32856 to coding implications.

Clarified nicotine/tobacco and marijuana use policy: marijuana prescribed by licensed practitioner is excluded from contraindication; commitment to risk reduction acceptable for urgent transplants.

Added pediatric specific indications including end-stage emphysema due to alpha-1 antitrypsin deficiency and alveolar capillary dysplasia, pulmonary vein stenosis refractory to intervention, and pulmonary veno-occlusive disease.

Revised adult and pediatric criteria to align with ISHLT 2021 consensus document.

10+Key absolute contraindications listed

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9Major adult disease categories referenced

9CPT/HCPCS codes listed

Coverage Summary

This policy defines medical necessity criteria for lung transplantation for non-Medicare Centene-affiliated health plans and applies to members/enrollees with chronic, end-stage lung disease. It requires failure of maximal medical (including pulmonary rehabilitation when applicable) or surgical therapy and specifies disease-specific eligibility thresholds, absolute contraindications, and documentation/prior authorization expectations. The policy is based on and references the ISHLT 2021 Consensus Document for selection of lung transplant candidates and is current for non-Medicare plans.

Key statistics summarized in the policy include counts of referenced major adult disease categories and listed procedure codes: the policy references multiple major disease categories for transplantation consideration (e.g., ILD, CF/bronchiectasis, COPD, pulmonary vascular disease, LAM, graft failure, ARDS, alveolar capillary dysplasia, pulmonary vein stenosis, pulmonary veno-occlusive disease) and enumerates procedure CPT/HCPCS codes for donor procurement, transplant procedures, and backbench preparation.

Medical-Necessity Criteria

Medically Necessary (Non-Medicare health plans)

Lung transplantation is medically necessary when ALL of the following are met:

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Absolute Contraindications / Not Covered

Does not have ANY absolute contraindications

Absolute contraindications - standalone

Malignancy with high risk of recurrence or death related to cancer
GFR: Glomerular filtration rate < 40 mL/min/1.73m2 unless being considered for multi-organ transplantGFR < 40 mL/min/1.73m2
Acute renal failure with rising creatinine on dialysis and low likelihood of recovery
Acute liver failure, or cirrhosis with portal hypertension or synthetic dysfunction unless being considered for multi-organ transplant

Coding

Covered CPT Codes (lung transplant procedures / donor prep / donor pneumonectomy)CPTCovered

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor
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
32855	Backbench standard preparation of cadaver donor lung allograft prior to transplantation; unilateral
32856	Backbench standard preparation of cadaver donor lung allograft prior to transplantation; bilateral
S2060	Lobar lung transplantation
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; procurement, transplantation, and related complications; global definition including drugs, supplies, hospitalization, outpatient follow-up

Provider Actions

Prior Authorization

Prior authorization implied for transplant requests

Transplant requests require review against these medical necessity criteria prior to approval; providers should submit relevant clinical documentation to support criteria. Primary action: transplant requests require review against medical necessity criteria prior to approval.

Documentation Required

Document failure of maximal medical/surgical therapy

Providers must document that the member has failed maximal medical (including pulmonary rehabilitation when applicable) or surgical therapy prior to transplantation request. Pulmonary rehabilitation and any prior surgical therapy should be documented as part of the failure of maximal therapy.

Documentation Required

Document disease-specific thresholds

Background

Background: This policy is based primarily on the ISHLT 2021 Consensus Document for the Selection of Lung Transplant Candidates and is updated annually. It includes criteria for both pediatric and adult indications and frames donor lungs as a limited societal resource, emphasizing selection based on survival benefit and expected improvements in quality of life.

ISHLT 2021 Consensus Document (Leard et al. J Heart Lung Transplant. 2021).

Definitions

Maximal medical therapy: Includes appropriate medical management and pulmonary rehabilitation when applicable; may include surgical therapy where relevant.

6MWT: Six-minute walk test; desaturation <88% or decline >50 m in 6 months are qualifying criteria.

Revision History

02/26revisedLatest

Revised adult and pediatric interstitial lung disease criteria to include end-stage or refractory pulmonary alveolar proteinosis; multiple adult and pediatric criteria updated to align with ISHLT guidance; annual review and updates to criteria and codes.

02/25revised

Updated glomerular filtration rate from < 30 to < 40 mL/min/1.73m2 in Criteria I.C.2; added CD4 timing and chronic wasting/malnutrition language for HIV criteria; expanded substance use criteria and added abstinence documentation requirement; added pediatric indications including alveolar capillary dysplasia, pulmonary vein stenosis, and pulmonary veno-occlusive disease.

Policy Summary

PayerCentene

PolicyLung Transplantation

Policy CodePolicy CP.MP.57

Change TypeRevisedAddedClarified

Effective Date

Next Review Date

Key ActionProviders must document failure of maximal medical or surgical therapy and submit objective disease-specific data to support transplant requests.

SourceLink

On This Page

Recent stroke/MI: Stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within 30 dayswithin 30 days

Active disseminated infection: Active extrapulmonary or disseminated infection

Active TB: Active tuberculosis infection

HIV branch

HIV: CD4: CD4 cell count >200 cells/mm3 for at least three months before transplantationCD4 > 200 cells/mm3 for ≥ 3 months
HIV: opportunistic infections: Absence of active AIDS-defining opportunistic infection or malignancy
HIV: ART: Member/enrollee is currently on effective antiretroviral therapy (ART)
HIV: nutrition: Member/enrollee does not have chronic wasting or severe malnutrition

Cognitive impairment: Progressive cognitive impairment

Adherence: Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support

Other severe conditions: Other severe, uncontrolled medical condition expected to limit survival after transplant

Active substance use or dependence (including current tobacco use, vaping, marijuana use [unless prescribed by a licensed practitioner], or intravenous drug use) without convincing evidence of risk reduction behaviors (unless urgent transplant timelines are present, in which case a commitment to reducing behaviors is acceptable). Serial blood and urine testing may be used to verify abstinence from substances that are of concern

History of substance use abstinence: History of nicotine, tobacco, alcohol, or illicit drug use, without documentation noting abstinence from all (including nicotine replacement therapy) for ≥ six months prior to transplantAbstinence documented ≥ 6 months

The policy notes that some items listed as contraindications (for example, GFR < 40 mL/min/1.73m2 or acute liver failure or cirrhosis with portal hypertension or synthetic dysfunction) may be exceptions when the member is being considered for a multi-organ transplant evaluation, consistent with the criteria language allowing multi-organ transplant consideration.

Providers must provide objective data supporting disease-specific criteria to justify transplant candidacy.

Serial spirometry showing declines in FVC/FEV1
DLCO measurements
Six-minute walk test (6MWT) results (including desaturation or distance changes)
Right heart catheterization or echocardiogram data for pulmonary hypertension
Hospitalization and exacerbation history
Nutritional status / BMI

Documentation Required

Substance use and abstinence verification

For members with active or past substance use, providers should document evidence of risk reduction behaviors or abstinence, including serial blood and urine testing when applicable. For historical use, documentation of ≥ six months abstinence prior to transplant is required. When urgent transplant timelines are present, a documented commitment to reducing risky behaviors is acceptable. Marijuana prescribed by a licensed practitioner is excluded from the active use contraindication.

Billing Rule

Use listed CPT/HCPCS codes for transplant procedures

When billing for donor procurement, transplant procedures, and backbench preparation use the specified CPT and HCPCS/S codes as appropriate.

32850
32851
32852
32853
32854
32855
32856
S2060
S2152

04/24revised

Updated I.C.2 GFR threshold previously noted; expanded HIV qualifying criteria; updated pediatric FEV1 threshold to <30% for CF; other minor grammatical and criteria clarifications.

02/23added

Criteria I.C.14 updated to exclude prescribed marijuana from contraindication and allow commitment to reducing substance use behaviors if urgent transplant timelines are present; added pediatric indication for end-stage emphysema due to alpha-1 antitrypsin deficiency; added CPT codes 32850, 32855, and 32856 (noted in coding implications).

02/22added

Added CPT codes 32850, 32855, and 32856 to coding implications and clarified nicotine/tobacco abstinence contraindication; updates based on ISHLT 2021 guidance.

revised

Revision history notes multiple updates across sections including I.C.2 GFR changes, expansion of HIV criteria, substance use clarifications (I.C.13/I.C.14), pediatric indications additions, and alignment to ISHLT 2021 consensus document across adult and pediatric criteria.