ModifiedHealth-New-EnglandPolicy N/A

Transplants - Medical Policy

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This policy governs coverage and medical-necessity review for non-experimental human solid-organ and bone marrow/stem cell transplant services, including related donor, grafting, HLA testing, and transplant-center requirements for Commercial, Medicare Advantage, and Medicaid BeHealthy members.

Policy Summary

PayerHealth-New-England

PolicyTransplants - Medical Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewOct 1, 2025

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria with every transplant-related prior-authorization request.

SourceLink

POLICY UPDATE CHANGES

For the Medicare line of business, Medicare InterQual criteria were adopted for transplants.

The Policy Guidelines and Definitions section was updated.

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ModifiedHealth-New-EnglandPolicy N/A

Transplants - Medical Policy

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Sign up for all Health-New-England policy alerts

Know when Health-New-England releases new policies or updates existing guidance.

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Policy Summary

PayerHealth-New-England

PolicyTransplants - Medical Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewOct 1, 2025

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria with every transplant-related prior-authorization request.

SourceLink

POLICY UPDATE CHANGES

For the Medicare line of business, Medicare InterQual criteria were adopted for transplants.

The Policy Guidelines and Definitions section was updated.

Lines of business addressed

90 daysDonor-charge coverage limit

6Solid-organ categories

InterQualMedicare coverage criteria

Not coveredUterine transplants

Coverage Criteria

General transplant medical necessity

Covered as medically necessary when all of the following criteria are met:

Core transplant eligibility

A specialist provider has documented that the transplant procedure is for treatment of irreversible end-stage organ failure.
The member meets the eligibility requirements of the transplant center performing the transplant.
The member is willing and capable of following the post-transplant treatment plan.

Medicare transplant criteria

For Medicare members, the transplant must be performed through an applicable CMS-approved transplant program or center and reviewed under the applicable InterQual and/or National Coverage Determination criteria.

Applicable Medicare transplant criteria

Allogeneic hematopoietic stem cell transplantation.
Allogeneic hematopoietic stem cell transplantation in a clinical trial.
Autologous stem cell transplantation (AuSCT).
Adult liver transplantation.
Pediatric liver transplantation.
Intestinal and multivisceral transplantation.
Islet cell transplantation in the context of a clinical trial.

Treatment at a non-CMS-approved facility is not covered. Medicare transplant services must be provided through an applicable CMS-approved transplant program or center.

Costs for experimental or unproven procedures are not covered under this policy.

Transplant services are not covered when the member is actively abusing alcohol or drugs.

Travel and non-medical room and board for a live donor, recipient, or family members of the donor or recipient are not covered. For Medicare Advantage transplant services performed at a distant location, HNE provides reasonable transportation and accommodations.

Artificial or animal-to-human organ or tissue transplants are not covered.

Embryonic stem cell transplants are not covered.

Uterine transplants are not covered.

Human leukocyte antigen (HLA) typing of an embryo to identify a future suitable stem cell, tissue, or organ transplantation donor is considered experimental and investigational and is not covered.

Coding Guidance

Coding GuidanceCPT

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor.
32852	Lung transplant, single; with cardiopulmonary bypass.
32853	Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass.
32854	Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass.
32856	Backbench standard preparation of cadaver donor lung allograft prior to transplantation.
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection.
38214	Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion.
38215	Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer.
38240	Hematopoietic progenitor cell (HPC) allogeneic transplantation per donor.
33930	Donor cardiectomy-pneumonectomy (including cold preservation).

1–10 of 29

1/3

Transplant procedure and related codesmixedCovered

47147	Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each
47142	Donor hepatectomy, including cold preservation, from living donor; total right lobectomy
48550	Donor pancreatectomy, including cold preservation, with or without duodenal segment for transplantation
48551	Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation
48552	Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation; venous anastomosis, each
48554	Transplantation of pancreatic allograft
48556	Removal of transplanted pancreatic allograft
50300	Donor nephrectomy, including cold preservation; from cadaver donor, unilateral or bilateral
50320	Donor nephrectomy, including cold preservation; open, from living donor
50323	Backbench standard preparation of cadaver donor renal allograft prior to transplantation

1–10 of 24

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Experimental/investigational codesCPTExperimental

0664T	Donor hysterectomy, including cold preservation; open, from cadaver donor
0665T	Donor hysterectomy, including cold preservation; open, from living donor
0666T	Donor hysterectomy, including cold preservation; laparoscopic or robotic, from living donor
0667T	Recipient uterus allograft transplantation from cadaver or living donor
0668T	Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation
0669T	Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each
0607T	Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each

Provider Actions and Review Requirements

Documentation Required

Transplant Medical-Necessity Review

Before authorization, review whether the solid-organ or bone marrow/stem-cell transplant is medically necessary under the applicable criteria. A preferred facility is one that has a direct HNE contract or participates in an HNE-contracted transplant network for the requested service.

For Medicare members, use the applicable CMS-approved transplant program requirements, InterQual criteria, and Medicare National Coverage Determinations (NCDs).
Combinations of organs are reviewed based on each unique organ unless excluded under the policy's noncovered-services provisions.

Documentation Required

Specialist Documentation Required

The specialist provider must document that the transplant is intended to treat irreversible, end-stage organ failure. Include the diagnosis, clinical findings, and specialist assessment supporting the need for transplantation.

Policy Background

Transplant procedures replace diseased or failing organs or tissue with a healthy donor organ or living tissue. This policy addresses non-experimental human solid-organ and bone marrow/stem cell transplantation when the transplant is intended to maintain functional integrity and extend or improve the recipient’s quality of life. Solid-organ transplantation includes the kidney, heart, lung, liver, pancreas, and intestine; bone marrow/stem cell transplantation includes autologous and allogeneic transplantation.

Transplant Definitions

Transplant

DefinitionA non-experimental human organ transplant or the grafting of living tissue from its normal position to another site.

Organ or tissue sourceHuman organ or tissue from one person.

Experimental statusNon-experimental.

Solid Organ Transplant

KidneyIncluded as a solid organ transplant.

Heart, lung, or liverIncluded as solid organ transplants.

Pancreas or intestineIncluded as solid organ transplants.

General Transplant Candidate Criteria

General transplant candidate criteria

A transplant is medically necessary when all core candidate requirements are met:

Transplant candidate criteria

The transplant is being performed to treat irreversible end-stage organ failure.
A specialist provider has documented the indication for transplant.
The member meets the eligibility requirements of the transplant center performing the transplant.
The member is willing and capable of following the post-transplant treatment plan.

Contraindications and Exclusions

Transplant services are contraindicated for members with active alcohol or drug abuse, when treatment is provided at a non-CMS-approved facility, or when the procedure is experimental or unproven. These services are not covered under the policy.

Evaluation Requirements

Documentation Required

Complete the transplant evaluation

Before proceeding, ensure that a specialist provider documents irreversible end-stage organ failure and that the member is evaluated against the transplant center's eligibility requirements. The member must also be willing and capable of following the post-transplant treatment plan; for bone marrow transplantation, HLA testing may be performed when necessary to establish donor suitability.

Transplant Center Requirements

Prior Authorization

Confirm transplant-center requirements

Use a transplant facility that has a direct contract with HNE or is part of an HNE-contracted Transplant Network for preferred consideration. Medicare transplant services must use CMS-approved transplant programs or centers that meet institutional coverage criteria.

Post-Transplant and Related Coverage

Donor Charges

Recipient requirementThe HNE member must be the recipient of a human organ transplant.

Other insuranceThe donor's costs must not be covered by any other insurance.

Maximum coverage periodDonor charges are covered for no more than 90 days post-operatively or until the HNE member's coverage ends, whichever happens first.

Bone Marrow or Blood-Derived Stem-Cell Transplantation

Covered transplantation typesBone marrow or blood-derived stem cells may be peripheral or umbilical and may involve allogeneic or autologous harvesting and transplantation.

Related servicesCertain codes include related complications, cell preparation and storage, marrow ablative therapy, drugs, supplies, and hospitalization with outpatient follow-up.

Policy Summary

PayerHealth-New-England

PolicyTransplants - Medical Policy

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewOct 1, 2025

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria with every transplant-related prior-authorization request.

SourceLink

On This Page

Pancreas transplantation.

Pancreas transplantation in a clinical trial.

Heart transplantation.

Prior Authorization

Transplant-Center Eligibility

Document that the proposed transplant center meets the applicable HNE, transplant-network, CMS, or Medicare program requirements for the service being requested.

Treatment at a non-CMS-approved facility is not covered.
The member must meet the eligibility requirements of the transplant center performing the procedure.

Unsupported block type: prior_auth

Documentation Required

HLA Donor-Suitability Testing

For bone marrow transplant requests, document why human leukocyte antigen (HLA) testing is needed to establish donor suitability. HNE covers testing for A, B, or DR antigens, or any combination of these, when medically necessary for that purpose.

HLA typing of an embryo to identify a future suitable stem-cell, tissue, or organ-transplant donor is experimental and investigational.

Documentation Required

Provider-Supplied Clinical Evidence

The treating physician or primary care provider must submit the clinical information and supporting evidence needed to demonstrate that the patient meets the applicable criteria. This information is required for HNE's clinical review.

Include evidence supporting the requested treatment, testing, or surgical procedure.
Clinical review criteria may reflect current clinical literature, regulatory status, evidence-based guidelines, and relevant professional guidance.

Denial Risk

Key Noncovered Transplant Services

Do not assume that all transplant-related services are covered. Confirm the facility, procedure, member status, and benefit provisions before proceeding.

Non-CMS-approved facilities; experimental or unproven procedures; and artificial or animal-to-human organ or tissue transplants are not covered.
Transplants involving embryonic stem cells or the uterus are not covered.
Services are not covered when the member is actively abusing alcohol or drugs.
Travel and nonmedical room and board for a live donor, recipient, or family members are not covered; Medicare Advantage services at a distant location may qualify for reasonable transportation and accommodations.
If the HNE member is the recipient and the donor has no other insurance, donor charges may be covered for up to 90 days postoperatively or until the member's coverage ends, whichever comes first. HNE does not cover an HNE member donating to a non-HNE member.

Prior Authorization

Center Eligibility and Post-Transplant Adherence

Confirm both transplant-center eligibility and the member's ability and willingness to follow the post-transplant treatment plan. The request should document that the member can comply with required follow-up care, medications, monitoring, and other center-directed requirements.

The member must satisfy the eligibility requirements of the center performing the transplant.
Failure to demonstrate ability or willingness to follow the post-transplant care plan may affect authorization.

Denial Risk

Insufficient Clinical Documentation

A prior-authorization request may not be reviewable without adequate clinical documentation and supporting information. HNE cannot properly evaluate the request when the required evidence is missing or insufficient.

Obtain and submit the treating physician's or primary care provider's clinical evidence before requesting review.
Incomplete documentation may delay review or prevent a determination that the criteria are met.

Denial Risk

Benefit-Plan Coverage Still Applies

A determination that a transplant or related service is medically necessary does not guarantee payment. Coverage is governed by the member's benefit program, and exclusions or limitations in that program control if they conflict with this guideline.

Verify the member's benefit provisions before rendering services.
Coverage may also be affected by applicable state or federal law and CMS requirements for Medicare or Medicaid members.

Autologous Transplant

BloodThe person's own blood is removed.

Stem cellsThe person's own stem cells may be removed.

Return to same personThe removed blood or stem cells are later given back to that person.

Allogeneic Transplant

Donor sourceStem cells or blood come from a donor.

RecipientThe donated stem cells or blood are transferred to a recipient.

Transplant typeAllogeneic transplant.

Blood Marrow / Stem Cell Transplant

Autologous typeIncludes transplantation using a person's own blood or stem cells, which are later returned to that person.

Allogeneic typeIncludes transplantation of stem cells or blood from a donor to a recipient.

ScopeBlood marrow/stem cell transplantation includes both autologous and allogeneic transplantation types.

Additional careThe global definition may include medical and surgical, diagnostic, emergency, rehabilitative, and pre- and post-transplant care.

Solid-Organ Transplantation

Included proceduresCertain codes include procurement and transplantation of complete or segmental solid organs from deceased or living donors, including single or combination organs.

Included resourcesThe global definition may include drugs, supplies, and hospitalization with outpatient follow-up.

Additional servicesThe global definition may include medical and surgical, diagnostic, and emergency services, as well as related complications.