CurrentCentenePolicy CP.MP.138

Pediatric Heart Transplant

Defines medical necessity criteria, contraindications, and coding implications for heart transplantation and re-transplantation in pediatric members/enrollees (age <18) for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyPediatric Heart Transplant

Policy CodePolicy CP.MP.138

Change TypeAnnual review; multiple revisions

Effective Date

Next Review Date

Key ActionProviders must document stage of heart failure, the specific indication(s) for transplant, supporting objective data, and that reversible causes have been ruled out.

POLICY UPDATE CHANGES

Updated verbiage in I.D.10 regarding liver disease and removed I.D.18 BMI criterion; edited I.D.21 to remove sentence concerning serial blood and urine; removed Appendix A regarding BMI charts.

Updated I.D.1 GFR threshold from <40 to <30 mL/min/1.73m2 and expanded HIV qualifying criteria for candidates.

Added pulmonary hypertension criterion addressing risk of developing fixed, irreversible pulmonary vascular resistance (I.A.1.b.vi.a).

Moved 'all reversible causes ruled out' to I.C and reorganized contraindications into I.D; various edits to contraindications including addition of progressive cognitive impairment and clarifications on substance use.

Replaced prior nonadherence and psychological condition wording with 'Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.'

2Primary procedure CPT codes listed

20Contraindications listed

Re-transplantation specific criterion

3Documented quantitative thresholds (GFR, VO2, CD4)

Coverage Summary

Overview: This policy covers with criteria heart transplantation and re-transplantation for pediatric members/enrollees (age < 18) with end-stage heart disease. It defines required indications (Stage C or D heart failure and specified anatomic/physiologic conditions), required documentation, and contraindications that would preclude medical necessity for transplant or re-transplant. The scope includes primary heart transplant and re-transplantation (e.g., for moderate to severe cardiac graft vasculopathy).

Key outcomes from the evidence: reported overall pediatric post-transplant survival is approximately 90% at 1 year, 80% at 5 years, and 60% at 10 years, with median survival estimates provided by age group (for example, infants median survival ~22.3 years).

Key Clinical Thresholds

Peak VO2< 50% predicted for age and sex

Life expectancy≥ 2 years (in absence of cardiopulmonary disease)

GFR< 30 mL/min/1.73 m2 (contraindication unless multiorgan transplant)

CD4 cell count> 200 cells/mm3 required for HIV-positive candidates meeting other HIV criteria

Outcomes

1-year survival (approx.)90%

5-year survival (approx.)80%

10-year survival (approx.)60%

Median survival — infants22.3 years

Median survival — ages 1–518.4 years

Median survival — ages 6–1014.4 years

Median survival — ages 11+13.1 years

Medically Necessary Criteria

Contraindications / Not Medically Necessary

Contraindications (preclude medical necessity)

Heart transplant is not considered medically necessary when ANY of the following contraindications are present:

D.1 GFR: Glomerular filtration rate < 30 mL/min/1.73m2 unless being considered for multiorgan transplant< 30 mL/min/1.73m2
D.2 HIV infection exception
- HIV qualifying criteria
  - CD4 cell count >200 cells/mm3> 200 cells/mm3

Coding

Surgical Procedure Codes ReferencedCPT

33944	Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation
33945	Heart transplant, with or without recipient cardiectomy

Provider Actions

Documentation Required

Documentation of indication and staging

Providers must document stage of heart failure (e.g., Stage C or D), the specific indication(s) for transplant, supporting objective data (examples include peak VO2 percent predicted, growth failure attributable to heart disease, evidence of ventricular dysfunction), and that reversible causes have been ruled out.

Peak VO2 percent predicted (< 50% predicted for age and sex is referenced as severe limitation of exercise)
Growth failure attributable to heart disease
Evidence of ventricular dysfunction

Documentation Required

Document contraindications and exceptions

Document presence or absence of listed contraindications (including GFR, HIV status and viral load, malignancy risk, infections, substance use, social support and adherence capacity) and any qualifying exceptions (for example, HIV qualifying criteria met or consideration for multiorgan transplant).

Background

Background: The policy establishes medical necessity requirements for pediatric heart transplantation and re-transplantation and references guidance from the American Heart Association and ISHLT for evaluation and care of pediatric transplant candidates.

Pediatric heart failure staging and indications: The policy summarizes pediatric heart failure staging (Table 1) per Canter et al., noting Stage C as abnormal structure/function with past or present symptoms and Stage D as abnormal structure/function requiring continuous intravenous inotropes, prostaglandin E1, or mechanical ventilatory/circulatory support. Cardiomyopathy (especially dilated cardiomyopathy) is the most common indication for transplant in children.

Age distribution and survival context: The policy notes the distribution of pediatric transplant recipients by age (for example, about 24% infants, 25% ages 1–5, 16% ages 6–10, and 35% ages 11–17) and reiterates current survival rates of approximately 90% at 1 year, 80% at 5 years, and 60% at 10 years after transplantation.

Definitions (glossary)

Evidence (survival and epidemiology)

Revision History

12/22revised

Annual review. Added pulmonary hypertension criterion addressing risk of developing fixed, irreversible pulmonary vascular resistance (I.A.1.b.vi.a). Updated GFR threshold from <40 to <30 mL/min/1.73m2 and expanded HIV qualifying criteria; updated substance use language and other edits. Background and references reviewed and updated.

10/23revised

Annual review and approval. Added pulmonary hypertension criterion (I.A.1.b.vi.a), updated GFR threshold to <30 mL/min/1.73m2, expanded HIV qualifying criteria, and updated substance use language; background and references reviewed and approved.

02/22revised

Policy Summary

PayerCentene

PolicyPediatric Heart Transplant

Policy CodePolicy CP.MP.138

Change TypeAnnual review; multiple revisions

Effective Date

Next Review Date

Key ActionProviders must document stage of heart failure, the specific indication(s) for transplant, supporting objective data, and that reversible causes have been ruled out.

On This Page

Opportunistic infection: Absence of active AIDS-defining opportunistic infection (unless treated efficaciously or prevented)

ART: Member/enrollee is currently on effective ART (antiretroviral therapy)

D.3 Pulmonary vascular resistance: Severe, irreversible, fixed elevation of pulmonary vascular resistance

D.4 Pulmonary artery/vein hypoplasia: Severe hypoplasia of the central branch pulmonary arteries or pulmonary veins

D.5 Specific congenital lesion: Any specific congenital heart lesion, except in circumstances noted in I.A.

D.6 AL amyloidosis: Amyloid light-chain (AL) amyloidosis (exceptions may be made where curative therapy has been performed or is planned, e.g., stem cell transplant or liver transplant)

D.7 Retransplantation during acute rejection: Retransplantation when performed during an episode of ongoing, acute allograft rejection, even in the presence of graft vasculopathy

D.8 Early retransplantation: Retransplantation when performed during the first six months after primary transplantationwithin first 6 months

D.9 Malignancy: Malignancy with high risk of recurrence or death related to cancer (exceptions exist for cancers completely resected or treated with acceptable future risk)

D.10 Advanced liver disease: Advanced liver disease or cirrhosis, unless being considered for multi-organ transplant

D.11 Acute renal failure: Acute renal failure with rising creatinine or on dialysis and low likelihood of recovery

D.12 Other severe uncontrolled condition: Other severe uncontrolled medical condition expected to limit survival after transplant

D.13 Uncorrected atherosclerotic disease: Uncorrected atherosclerotic disease with suspected or confirmed end-organ ischemia or dysfunction

D.14 Chronic infection with virulent/resistant microbes: Chronic infection with highly virulent and/or resistant microbes that are poorly controlled pre-transplant

D.15 Active tuberculosis: Active tuberculosis infection

D.16 Progressive cognitive impairment: Progressive cognitive impairment

D.17 Chest wall/spinal deformity: Significant chest wall/spinal deformity expected to cause severe restriction after transplantation

D.18 Inability to adhere: Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support

D.19 Social support absent: Absence of an adequate or reliable social support system

D.20 Active substance use/dependence: Active substance use or dependence including current tobacco use, vaping, marijuana use (unless prescribed by a licensed practitioner), or IV drug use without convincing evidence of risk reduction behaviors such as meaningful and/or long-term participation in therapy for substance abuse and/or dependence (unless urgent transplant timelines are present, in which case a commitment to reducing behaviors is acceptable)

Glomerular filtration rate (GFR) — threshold: < 30 mL/min/1.73 m2 (unless being considered for multiorgan transplant)
HIV status/viral load and qualifying criteria (CD4 cell count > 200 cells/mm3; absence of active AIDS-defining opportunistic infection unless treated; currently on effective ART)
Malignancy risk (malignancy with high risk of recurrence or death related to cancer; exceptions may exist)
Chronic or acute infections (e.g., chronic infection with highly virulent/resistant microbes; active tuberculosis)
Active substance use or dependence (including tobacco, vaping, marijuana use unless prescribed, IV drug use) and required evidence of risk-reduction commitment when urgent timelines exist
Absence or presence of adequate/reliable social support system
Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support

Billing Rule

Use of referenced CPT codes for transplant procedures

When billing for heart transplant procedures, reference CPT codes 33944 and 33945 as applicable; providers should reference current coding guidance prior to claim submission.

CPT 33944
CPT 33945
Refer to the most up-to-date professional coding guidance prior to claim submission

Logged history. Moved 'all reversible causes ruled out' to I.C and reorganized contraindications into I.D; edits to contraindications including addition of GFR, acute liver failure/cirrhosis, acute renal failure, HIV infection with detectable viral load, progressive cognitive impairment, and rewording of substance use and other items.

08/21clarified

Replaced prior nonadherence and psychological condition wording with 'Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.' (header changed to 'Revision Date = 08/21').

08/25revisedLatest

Revision Date = 08/25 annual review. Updated verbiage in I.D.10 regarding liver disease; removed I.D.18 BMI criterion and Appendix A regarding BMI charts; edited I.D.21 to remove sentence concerning serial blood and urine. Background updated and policy reviewed by internal specialist.