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    v1.0.28
    OpenPayerPolicy UpdatesTransplantDevoted Health Lung Transplant Coverage | OpenPaye…
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    CurrentDevoted HealthPolicy UMGT.CL.0043

    Lung Transplantation

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    This policy governs Devoted Health coverage and medical necessity criteria for lung transplantation, including candidate requirements, exclusions, and applicable procedure codes. It applies to all Devoted plans.

    Policy Summary
    PayerDevoted Health
    PolicyLung Transplantation
    Policy CodePolicy UMGT.CL.0043
    Change TypeAnnual updateno material clinical or coverage changes
    Effective DateMar 1, 2023
    Last ReviewSep 8, 2025
    Next Review DateSep 1, 2026
    Key ActionConfirm adequate cardiac status and evaluate other organ dysfunction or medical problems before requesting lung transplantation coverage.
    SourceLink
    POLICY UPDATE CHANGES

    The September 2025 annual update made no changes to coverage criteria and updated references and validated current practice guidelines.

    5Required medical necessity criteria
    11Listed non-covered scenarios
    6Applicable procedure codes
    >50%2-year mortality risk without transplantation

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    >80%
    5-year post-transplant survival likelihood

    Coverage Criteria

    Lung transplantation medical necessity

    Covered when ALL of the following medical necessity criteria are met.

    Lung transplant medical necessity

    • Disease severity and treatment failure: The patient has irreversible, progressively debilitating, end-stage pulmonary disease that is unresponsive to maximum alternative medical or surgical therapies.
    • Symptoms and quality of life: The patient has severe, progressive symptoms despite optimal medical management that result in an unacceptable quality of life.
    • Post-transplant participation: The patient is willing and capable of participating in and complying with the post-transplantation treatment plan necessary to regain maximum function.
    • Cardiac status: The patient has adequate cardiac status, as determined by the patient's medical professional, to undergo lung transplantation.
    • Other organ function and medical conditions: The patient is free of any other organ dysfunction or medical problem that would significantly jeopardize the outcome of lung transplantation.

    Clinical candidate considerations

    Clinical guidance identifies the following general candidate considerations for adults with chronic, end-stage lung disease.

    General candidate considerations

    • Mortality risk without transplantation: The patient has a high risk of death from lung disease if lung transplantation is not performed.>50% within 2 years
    • Post-transplant survival likelihood: The patient has a high likelihood of 5-year post-transplant survival from a general medical perspective, provided that there is adequate graft function.>80% at 5 years

    Coverage may be excluded when the patient has coronary artery disease that is not amenable to percutaneous intervention or bypass grafting, or when the disease is associated with significant impairment of left ventricular function.

    Coverage may be excluded when the patient has a confirmed chest wall or spinal deformity that would pose a contraindication to lung transplantation.

    Coverage may be excluded when the patient has a malignancy expected to significantly limit future survival.

    Coverage may be excluded when the patient has persistent and recurrent systemic infections that have been unsuccessfully treated.

    Coverage may be excluded when the patient has a confirmed systemic illness or comorbidity expected to substantially negatively affect successful completion or the outcome of lung transplant surgery.

    Coverage may be excluded when the patient demonstrates a pattern of noncompliance with current treatment regimens that would place the transplanted lung at serious risk for postoperative failure.

    Coverage is not available when the member's Evidence of Coverage does not include coverage for organ transplantation.

    Devoted Health does not cover organs sold rather than donated to the recipient.

    Experimental or investigational transplants are not covered unless performed in a qualified Medicare-approved clinical trial.

    Coverage may be excluded when the transplant facility is not approved by CMS as meeting institutional coverage criteria for transplants.

    Nationally non-covered indications in the applicable National Coverage Determination (NCD) are excluded, when applicable.

    Applicable Coding and Clinical Thresholds

    Covered CPT CodesCPTCovered
    32850Donor pneumonectomy(s) (including cold preservation), from cadaver donor
    32851Lung transplant, single; without cardiopulmonary bypass
    32852Lung transplant, single; with cardiopulmonary bypass
    32853Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass
    32854Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass
    34714Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List
    Risk of death without transplantation
    Risk measureRisk of death from lung disease if transplantation is not performed
    Threshold>50%
    Time frameWithin 2 years
    Post-transplant survival likelihood
    Outcome measurePost-transplant survival from a general medical perspective
    Threshold>80%
    Time frame and conditionAt 5 years, provided that there is adequate graft function

    Provider Actions and Denial Risks

    Denial Risk

    Screen for contraindications before requesting coverage

    Coverage may be denied if the patient has a contraindicating condition, including coronary artery disease that is not amenable to percutaneous intervention or bypass grafting, significant impairment of left ventricular function, or another listed high-risk condition.

    • Confirmed chest wall or spinal deformity that would pose a contraindication to transplantation.
    • Malignancy expected to significantly limit future survival.
    • Persistent and recurrent systemic infections that have been unsuccessfully treated.
    • Systemic illness or comorbidities expected to substantially negatively impact successful completion or outcome of lung transplant surgery.
    • A demonstrated pattern of noncompliance with current treatment regimens that would place a transplanted lung at serious risk for failure postoperatively.
    Denial Risk

    Verify benefit, facility, organ source, and coverage

    Background

    Lung transplantation is the surgical replacement of part or all of a patient's lung or lungs with organs from a living or deceased donor. It is generally a palliative, last-resort treatment for end-stage pulmonary disease that has not responded to alternative medical or surgical treatment. The primary goal is projected survival benefit, with quality-of-life improvement also considered.

    Definitions

    Lung transplantation
    ProcedureSurgical replacement of the lung or lungs
    Disease contextEnd-stage pulmonary disease
    Donor source and extentA partial (lobar) or whole lung or lungs from a living or deceased donor
    CMS
    AcronymCMS
    Full nameCenters for Medicare and Medicaid Services
    DefinitionCenters for Medicare and Medicaid Services

    Lung Transplant Candidate Criteria

    Lung transplant candidate criteria

    Lung transplantation is covered when ALL candidate medical necessity criteria are met.

    • End-stage pulmonary disease: The candidate has irreversible, progressively debilitating end-stage pulmonary disease that is unresponsive to maximum alternative medical or surgical therapies.
    • Severe symptoms and unacceptable quality of life: The candidate has severe, progressive symptoms despite optimal medical management that result in an unacceptable quality of life.
    • Post-transplant treatment participation: The candidate is willing and capable of participating in and complying with the post-transplantation treatment plan necessary to regain maximum function.

    Contraindications

    Lung transplantation may be contraindicated by coronary artery disease that is not amenable to intervention or bypass grafting or that causes significant left ventricular impairment; a contraindicating chest wall or spinal deformity; malignancy expected to significantly limit future survival; persistent and recurrent unsuccessfully treated systemic infection; systemic illness or comorbidities expected to substantially impair transplant completion or outcome; or demonstrated treatment noncompliance placing the transplanted lung at serious risk for postoperative failure.

    Evaluation Requirements

    Documentation Required

    Complete the required candidate evaluation

    The patient's medical professional must determine that cardiac status is adequate for lung transplantation. The candidate must also be evaluated for other organ dysfunction or medical problems that could significantly jeopardize the transplant outcome, and the candidate's ability and willingness to participate in and comply with the post-transplant treatment plan must be established.

    • Document adequate cardiac status for lung transplantation.
    • Evaluate for other organ dysfunction or medical problems that could significantly jeopardize the transplant outcome.
    • Establish the candidate's ability and willingness to participate in and comply with the post-transplant treatment plan.

    Center Requirements

    Prior Authorization

    Confirm CMS-approved transplant facility

    Use a transplant facility approved by CMS as meeting institutional coverage criteria for transplants. A facility that does not meet this requirement is a non-covered setting under the policy.

    • Confirm CMS approval of the transplant facility before the procedure.
    Policy Summary
    PayerDevoted Health
    PolicyLung Transplantation
    Policy CodePolicy UMGT.CL.0043
    Change TypeAnnual updateno material clinical or coverage changes
    Effective DateMar 1, 2023
    Last ReviewSep 8, 2025
    Next Review DateSep 1, 2026
    Key ActionConfirm adequate cardiac status and evaluate other organ dysfunction or medical problems before requesting lung transplantation coverage.
    SourceLink
    On This Page
    Coverage CriteriaApplicable Coding and Clinical ThresholdsProvider Actions and Denial RisksBackgroundDefinitionsLung Transplant Candidate CriteriaContraindicationsEvaluation RequirementsCenter Requirements

    Verify coverage and transplant eligibility before proceeding. Coverage may be denied when the member's Evidence of Coverage does not include organ transplantation, the organ is sold rather than donated, the transplant is experimental or investigational outside a qualified Medicare-approved clinical trial, the facility lacks CMS approval, or the indication is nationally non-covered under the applicable NCD.

    • Confirm that the member's Evidence of Coverage includes organ transplantation.
    • Use an organ that is donated rather than sold to the recipient.
    • For experimental or investigational transplants, confirm that the procedure is performed in a qualified Medicare-approved clinical trial.
    • Confirm that the facility is approved by CMS as meeting institutional coverage criteria for transplants.
    • Check applicable NCDs for nationally non-covered indications.
    LCD
    AcronymLCD
    Full nameLocal Coverage Determination
    DefinitionLocal Coverage Determinations
    NCD
    AcronymNCD
    Full nameNational Coverage Determination
    DefinitionNational Coverage Determination
    Adequate cardiac status:
    The candidate has adequate cardiac status, as determined by the patient's medical professional, to undergo lung transplantation.
  1. No jeopardizing organ dysfunction or medical problem: The candidate is free of any other organ dysfunction or medical problem that would significantly jeopardize the outcome of lung transplantation.