CurrentFidelis CarePolicy CP MP.138

Clinical Policy: Pediatric Heart Transplant

Defines medical necessity criteria, contraindications, and coding implications for pediatric (age <18) heart transplantation and re-transplantation for health plans affiliated with Centene Corporation (Fidelis Care). Includes indications (end-stage heart disease), exclusions/contraindications, and referenced CPT codes for transplant procedures.

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Pediatric Heart Transplant

Policy CodePolicy CP MP.138

Change TypeCriteria revisions and annual updates

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must document pediatric age (<18), specific indication, exercise limitation (max VO2 <=50% predicted when claimed), and life expectancy >=2 years before listing for transplant.

SourceLink

POLICY UPDATE CHANGES

Updated I.D.1. GFR threshold from 40 to 30 mL/min/1.73 m2 and expanded HIV qualifying criteria; updated substance use wording to exclude prescribed marijuana and allow commitment to risk reduction with urgent timelines.

Added criterion for pulmonary hypertension with potential risk of developing fixed, irreversible pulmonary vascular resistance that could preclude future orthotopic transplant.

Annual reviews updated background and non‑clinical verbiage; Appendix A (BMI charts) removed in recent revisions.

Removed ICD-10 codes from appendices and updated coding implications and background; CPT codes 33944 and 33945 referenced for informational purposes.

2Primary vs Re-transplant categories

~20Contraindications listed (approximate)

Key CPT codes referenced

Coverage Summary

Overview: This policy (Policy Number CP MP.138, effective 2025-08-01) defines medical necessity criteria and contraindications for pediatric heart transplantation and re-transplantation for members age < 18 years. Coverage stance: Covered with criteria — heart transplant is medically necessary when all specified pediatric indications, functional thresholds, life-expectancy, and contraindication rules are met.

Evidence summary: Pediatric post-transplant survival is approximately 90% at 1 year, 80% at 5 years, and 60% at 10 years. Median survival by age at transplant is reported as: Infants: 22.3 years; ages 1–5: 18.4 years; ages 6–10: 14.4 years; ages 11+: 13.1 years.

Key Clinical Thresholds

Maximum oxygen consumption<= 50% predicted for age and sex

Life expectancy without cardiopulmonary disease>= 2 years

Glomerular filtration rate cutoff< 30 mL/min/1.73 m2 (contraindication unless multiorgan transplant considered)

CD4 cell count (HIV)> 200 cells/mm3

Medically Necessary Criteria

Medically Necessary - Pediatric Heart Transplant (members < 18 years)

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

ref”:

Not Appropriate / Contraindications

Coding

Transplant Procedure CPT codes referencedCPTCovered

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 / Prior Authorization

Prior Authorization

Prior authorization required per plan policies

Heart transplant and re-transplant procedures require review for medical necessity against the policy criteria and prior authorization according to Health Plan procedures. Include transplant procedure CPT codes 33944 and 33945 when requesting authorization.

33944
33945

Documentation Required

Document indications and functional status

Document that the patient is pediatric (age <18), the specific indication for transplant (for example Stage D heart failure, cardiomyopathy, or congenital heart disease), the degree of exercise limitation with objective evidence such as maximum oxygen consumption ≤50% predicted for age and sex when claimed, and an estimated life expectancy in the absence of cardiopulmonary disease ≥2 years.

Background

Background: Pediatric heart disease is progressive and heart transplantation is the treatment of choice for end‑stage pediatric heart disease. Cardiomyopathy is the most common indication for pediatric heart transplant, with dilated cardiomyopathy the most frequent subtype followed by hypertrophic and restrictive forms.

Survival and age-related outcomes: Current recipient survival is approximately 90% (1 year), 80% (5 years), and 60% (10 years). Reported median survivals by age at transplant are: Infants: 22.3 years; ages 1–5: 18.4 years; ages 6–10: 14.4 years; ages 11+: 13.1 years.

Notes on appendices and coding: Appendix A (BMI charts) was removed in recent revisions and ICD-10 codes were removed from appendices; CPT codes 33944 and 33945 are referenced for informational purposes related to transplant procedures.

Definitions and Evidence

Definitions: Stage D heart failure — pediatric stage characterized by abnormal cardiac structure or function requiring continuous infusion of intravenous inotropes or prostaglandin E1, mechanical ventilatory support and/or mechanical circulatory support (per Table 1 definitions referenced).

Clinical Outcomes

Pediatric transplant survival (1/5/10 years)Approximately 90%, 80%, and 60% respectively

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

Revision History

10/23Updated I.D.1. GFR threshold from 40 to 30 mL/min/1.73 m2 and expanded HIV qualifying criteria; updated substance use wording to exclude prescribed marijuana and allow commitment to risk reduction with urgent timelines.Latest

Updated I.D.1. from GFR 40 mL/min/1.73m2 to GFR 30 mL/min/1.73m2; expanded HIV qualifying criteria; revised substance use language to exclude prescribed marijuana and permit commitment to risk reduction for urgent transplant timelines.

10/23Added to I.A.I.b.vi.a per revision history.Latest

Added criterion for pulmonary hypertension with potential risk of developing fixed, irreversible pulmonary vascular resistance that could preclude orthotopic heart transplantation.

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Pediatric Heart Transplant

Policy CodePolicy CP MP.138

Change TypeCriteria revisions and annual updates

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must document pediatric age (<18), specific indication, exercise limitation (max VO2 <=50% predicted when claimed), and life expectancy >=2 years before listing for transplant.

SourceLink

On This Page

Documentation Required

Rule out reversible causes

Ensure and document that all reversible causes of heart failure have been evaluated and ruled out prior to listing for transplant.

Documentation Required

HIV specific documentation when applicable

For HIV-positive candidates, document HIV-specific information to support consideration: viral load status (no detectable viral load preferred), CD4 cell count >200 cells/mm3, current effective antiretroviral therapy (ART), and absence of active AIDS‑defining opportunistic infections or documentation that such infections have been effectively treated or prevented.

Denial Risk

Contraindication-based denial risk

Claims may be denied or considered not medically necessary when listed contraindications are present. Examples include glomerular filtration rate <30 mL/min/1.73 m2 (unless being considered for multiorgan transplant), uncontrolled or chronic severe infection, malignancy with high risk of recurrence or death related to cancer, and active substance use or dependence without convincing evidence of risk-reduction behaviors (exceptions noted for urgent transplant timelines).

08/24Annual review; background/verbiage update with no clinical significance.

Annual review updated description and background with no clinical significance; references reviewed and updated.

08/25Annual review; background/verbiage update with no clinical significance.

Annual review updated verbiage regarding liver disease and removed Appendix A (BMI charts); background updated with no clinical significance.

12/22Coding and appendix revisions.

Removed ICD-10 codes from appendices and updated coding implications and background; CPT codes 33944 and 33945 referenced for informational purposes.