Lung Transplantation (Medicare)
Defines medical necessity criteria for lung transplantation for Medicare health plans affiliated with Centene, based primarily on ISHLT 2021 consensus guidance, including candidate selection, absolute contraindications, disease-specific indications for adults and pediatrics, and coding implications.
Updated GFR threshold in Criteria I.C.2. (revisions alternated between <30 and <40 mL/min/1.73m2; current policy lists GFR <40 mL/min/1.73m2 as an absolute contraindication unless multi‑organ transplant).
Expanded HIV criteria in I.C.9 to specify CD4 >200 cells/mm3 for at least three months prior to transplant, absence of AIDS-defining conditions, current effective ART, and absence of chronic wasting/severe malnutrition.
Revised FEV1 threshold in criteria for CF/bronchiectasis (I.D.2.a.1.) from <25% to <30% predicted in applicable populations.
Added pediatric-specific qualifying disease states: alveolar capillary dysplasia, pulmonary vein stenosis refractory to intervention, and pulmonary veno-occlusive disease.
Clarified and expanded substance use criteria: active substance use/dependence is a contraindication without convincing risk‑reduction evidence; documentation of abstinence (≥6 months) or commitment to risk reduction and serial testing may be used when urgent timelines apply.
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