CurrentCentenePolicy CP.MP.132

Heart-Lung Transplant (PDF)

Defines medical necessity criteria, disease severity requirements, contraindications, and coding implications for heart-lung transplant for Centene-affiliated health plans (adult and pediatric). Governs coverage determination for combined heart-lung transplantation.

Policy Summary

PayerCentene

PolicyHeart-Lung Transplant (PDF)

Policy CodePolicy CP.MP.132

Change TypeRevisions to clinical criteria and contraindications (annual reviews)

Effective Date

Next Review Date

Key ActionProvide documentation of NYHA class (≥ III) for adults or AHA Stage C/D for pediatrics, and evidence that life expectancy in absence of cardiopulmonary disease is ≥ two years.

SourceLink

POLICY UPDATE CHANGES

02/25 annual review: multiple criterion changes including age thresholds, congenital heart disease criteria, contraindications, and table changes to AHA stages.

04/25 revision: updated wording in I.A.1.h.iv. and I.A.2.h.iv. from 'could preclude heart failure' to 'could preclude heart transplant'.

02/24 annual review: added indication to I.A.1.j., expanded I.C.1, removed active peptic ulcer disease as contraindication, and other wording updates.

2Age cohorts defined

≥18Adult age threshold

≥2 yrs

Required life expectancy

CD4 >200HIV CD4 threshold

Coverage Summary

This policy (CP.MP.132) addresses medical necessity criteria for heart-lung transplantation for Centene-affiliated health plans, covering both adult and pediatric candidates. Status: CURRENT. Coverage stance: covered_with_criteria.

Scope: defines required indications, disease severity thresholds (adult: NYHA class ≥ III; pediatric: AHA Stage C/D), contraindications, and documentation/coding implications governing coverage determinations for combined heart-lung transplantation.

Effective/last review date: 04/25 (Date of Last Revision per policy header and revision log).

Key thresholds and quick facts

Life expectancy absent cardiopulmonary disease≥ two years

CD4 cell count for HIV+ candidates> 200 cells/mm3 for at least 3 months before transplantation

GFR exclusion thresholdGlomerular filtration rate < 30 mL/min/1.73m2 is a contraindication (unless multi-organ transplant)

Substance abstinence documentationDocumentation of abstinence for ≥ six months prior to transplant or commitment to reduce behaviors if urgent timelines

Age cohorts defined2 cohorts (Age ≥ 18 and Age < 18)

Adult age threshold≥ 18 years

Medically Necessary Criteria

Heart-lung transplant is medically necessary when ALL of the following are met:

ALL of the following

End-stage heart and end-stage lung disease due to one of the listed indications
- Age ≥ 18: any of the following
  - Irreversible primary pulmonary hypertension with severe heart failure
  - Nonspecific Idiopathic severe pulmonary fibrosis
  - Eisenmenger syndrome with irreversible pulmonary hypertension and heart failure

Not Medically Necessary / Contraindications

Contraindications / Exclusions

Does NOT have any listed contraindications

HIV infection
- CD4 cell count > 200 cells/mm3 for at least 3 months before transplantation> 200 cells/mm3 for ≥ 3 months
- Absence of active AIDS-defining opportunistic infection (unless treated efficaciously or prevented)
- Member/enrollee is currently on effective antiretroviral therapy (ART)
- Member/enrollee does not have chronic wasting or severe malnutrition

Provider Actions

Documentation Required

Document disease severity and life expectancy

Provide documentation of NYHA class (≥ III) for adults or AHA Stage C/D for pediatrics, and evidence that life expectancy in absence of cardiopulmonary disease is ≥ two years.

NYHA class ≥ III for adults or AHA Stage C or D for pediatrics
Documentation that life expectancy in the absence of cardiopulmonary disease is ≥ 2 years

Documentation Required

Document contraindication exceptions for HIV

For HIV-positive candidates with detectable viral load, document CD4 >200 cells/mm3 for ≥3 months, absence/treatment of opportunistic infections, effective ART, and absence of severe malnutrition to qualify.

CD4 cell count > 200 cells/mm3 for at least 3 months before transplantation

Coding

Informational procedure codes referencedCPT/HCPCS/mixed

33930	Donor cardiectomy-pneumonectomy (including cold preservation)
33933	Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation.
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition

Background

Background: Heart-lung transplantation is indicated for selected patients with simultaneous end-stage heart and end-stage lung disease. Common indications include complex congenital heart disease with Eisenmenger syndrome, primary pulmonary hypertension, and cystic fibrosis.

Donor limitations: The frequency of heart-lung transplantation is limited by the number of suitable donors.

Advances in medical therapy: Availability of new medical therapies has decreased the overall need for heart-lung transplantation.

Additional context: The policy includes informational procedure codes (e.g., 33930, 33933, 33935, S2152) for claims and coding reference; inclusion does not guarantee coverage.

Selected survival evidence

ISHLT survival median (2010-2017)6.5 years

ISHLT survival median (1992-2001)3.7 years

Definitions

Scope / Policy Identifiers

Revision History

02/25revisedLatest

02/25 annual review: multiple criterion changes including age thresholds, congenital heart disease criteria, contraindications, and table changes to AHA stages. Updated many specifics in I.A., I.B., and I.C.; removed pediatric Alpha-1 antitrypsin indication earlier; references reviewed.

04/25revised

04/25 revision: updated wording in I.A.1.h.iv. and I.A.2.h.iv. from 'could preclude heart failure' to 'could preclude heart transplant'. Clarifies future risk refers to transplant candidacy.

02/24revised

Policy Summary

PayerCentene

PolicyHeart-Lung Transplant (PDF)

Policy CodePolicy CP.MP.132

Change TypeRevisions to clinical criteria and contraindications (annual reviews)

Effective Date

Next Review Date

Key ActionProvide documentation of NYHA class (≥ III) for adults or AHA Stage C/D for pediatrics, and evidence that life expectancy in absence of cardiopulmonary disease is ≥ two years.

SourceLink

On This Page

Cystic fibrosis with severe heart failure

Chronic obstructive pulmonary disease with severe heart failure

Emphysema with severe heart failure

Pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure

Congenital heart disease (CHD) meeting one of the following

Single ventricle CHD with Fontan circulation and one of
- Symptomatic heart failure (HF) and reduced systolic function (Class 1)
- Symptomatic HF, preserved systolic function, and abnormal systemic ventricular filling pressures (Class 1)
- Lymphatic abnormalities including plastic bronchitis and protein-losing enteropathy refractory to lymphatic interventions and medical management (Class 2a)
- Cirrhosis or CKD attributed to chronically elevated central venous pressures (Class 2a)
Single ventricle CHD and one of
- Palliation to a shunted circulation or a superior cavo-pulmonary anastomosis (first procedure of a staged Fontan) and prohibitive risk for further single ventricle palliation
- Cyanotic heart disease with severe atrio-ventricular valve regurgitation and prohibitive risk for operative repair
- Pulmonary atresia with an intact ventricular septum, right ventricular dependent coronary circulation, and atresia of at least one aorto-coronary ostium
HF symptoms or ventricular arrhythmias refractory to medical, interventional, and device therapies (Class 1)
Reactive pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of PVR that could preclude heart transplant in the future (Class 1)
Severe coronary artery disease or cardiomyopathy with irreversible pulmonary hypertension
Right ventricular failure with objective evidence of right ventricular fibrosis or infarction or refractory left ventricular failure

Age < 18: any of the following

Eisenmenger syndrome
Heart re-transplant
Lung re-transplant
Pulmonary alveolar proteinosis
Primary pulmonary hypertension
Pulmonary vascular disease
Restrictive cardiomyopathy
Congenital heart disease meeting one of the following
- Single ventricle CHD with Fontan circulation and one of
  - Symptomatic HF and reduced systolic function (Class 1)
  - Symptomatic HF, preserved systolic function, and abnormal systemic ventricular filling pressures (Class 1)
  - Lymphatic abnormalities including plastic bronchitis and protein-losing enteropathy refractory to lymphatic interventions and medical management (Class 2a)
  - Cirrhosis or CKD attributed to chronically elevated central venous pressures (Class 2a)
- Single ventricle CHD and one of
  - Palliation to a shunted circulation or a superior cavo-pulmonary anastomosis (first procedure of a staged Fontan) and prohibitive risk for further single ventricle palliation
Cystic fibrosis with progressive, irreversible cardiac dysfunction
Dilated cardiomyopathy

Meets disease severity criteria

Age ≥ 18 years: New York Heart Association (NYHA) class III or IV; Age < 18 years: American Heart Association Stage C or Stage D heart disease
Life expectancy in the absence of cardiopulmonary disease ≥ two years≥ two years

Does NOT have any listed contraindications

HIV infection
- CD4 cell count > 200 cells/mm3 for at least 3 months before transplantation> 200 cells/mm3 for ≥ 3 months
- Absence of active AIDS-defining opportunistic infection (unless treated efficaciously or prevented)
- Member/enrollee is currently on effective antiretroviral therapy (ART)
- Member/enrollee does not have chronic wasting or severe malnutrition
Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support
Severe hypoplasia of the central branch pulmonary arteries or pulmonary veins
Current episode of ongoing acute allograft rejection and retransplantation is requested
Less than six months have passed since the primary transplantation and retransplantation is requested< 6 months
Malignancy with high risk of recurrence or death related to cancer
Acute renal failure with rising creatinine or 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
Stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within 30 dayswithin 30 days
Glomerular filtration rate < 30 mL/min/1.73m2, unless being considered for multi-organ transplantGFR < 30 mL/min/1.73m2
Septic shock
Active extrapulmonary or disseminated infection
Active tuberculosis infection
Progressive cognitive impairment
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 nicotine, tobacco, alcohol, or illicit drug use, without documentation noting abstinence from all (including nicotine replacement therapy) for ≥ six months prior to transplant≥ six months abstinence
Lung transplantation alone will restore right ventricular function (therefore heart-lung transplant not indicated)

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

Severe hypoplasia of the central branch pulmonary arteries or pulmonary veins

Current episode of ongoing acute allograft rejection and retransplantation is requested

Less than six months have passed since the primary transplantation and retransplantation is requested< 6 months

Malignancy with high risk of recurrence or death related to cancer

Acute renal failure with rising creatinine or 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

Stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within 30 dayswithin 30 days

Glomerular filtration rate < 30 mL/min/1.73m2, unless being considered for multi-organ transplantGFR < 30 mL/min/1.73m2

Active extrapulmonary or disseminated infection

Active tuberculosis infection

Progressive cognitive impairment

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 nicotine, tobacco, alcohol, or illicit drug use, without documentation noting abstinence from all (including nicotine replacement therapy) for ≥ six months prior to transplant≥ six months abstinence

Lung transplantation alone will restore right ventricular function (therefore heart-lung transplant not indicated)

Absence of active AIDS-defining opportunistic infection (or treated/prevented)

Member/enrollee currently on effective antiretroviral therapy (ART)

No chronic wasting or severe malnutrition

Documentation Required

Substance use verification

Provide evidence of abstinence for nicotine, tobacco, alcohol, or illicit drug use for ≥ six months prior to transplant or documented commitment to reducing behaviors if urgent transplant timelines exist; serial blood/urine testing may be used.

Documentation of abstinence from nicotine, tobacco, alcohol, and illicit drugs for ≥ six months prior to transplant
If urgent transplant timelines exist, documented commitment to reducing substance use behaviors is acceptable
Serial blood and urine testing may be used to verify abstinence

Billing Rule

Use referenced procedure codes for claims

Claims for heart-lung transplant and related donor procedures should reference appropriate CPT/HCPCS codes such as 33930, 33933, 33935 and S2152 as applicable; codes listed are informational and do not guarantee coverage.

33930
33933
33935
S2152

02/24 annual review: added indication to I.A.1.j., expanded I.C.1, removed active peptic ulcer disease as contraindication, and other wording updates. Multiple edits to criteria and contraindications; references updated.

02/23 and 05/22revised

02/23 and 05/22 annual reviews: removed pediatric Alpha-1 antitrypsin deficiency; updated substance use language to exclude prescribed marijuana and require commitment to reducing use if urgent timelines are present. Criteria I.C.16 updated to exclude marijuana when prescribed; added commitment acceptable for urgent timelines.

Cyanotic heart disease with severe atrio-ventricular valve regurgitation and prohibitive risk for operative repair

Pulmonary atresia with an intact ventricular septum, right ventricular dependent coronary circulation, and atresia of at least one aorto-coronary ostium

Neonatal hypoplastic left heart syndrome with high-risk features including HF symptoms, ventricular dysfunction, left ventricular-coronary artery fistulae

HF symptoms or ventricular arrhythmias refractory to medical, interventional, and device therapies (Class 1)

Reactive pulmonary hypertension and a potential risk of developing fixed, irreversible elevation of PVR that could preclude heart transplant in the future (Class 1)

Neonatal cyanotic CHD with high-risk features (Class 2a)