Modifiedjohns_hopkins_health_plansPolicy CMS19.05

Solid Organ Transplantation — Coverage Criteria

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Defines Johns Hopkins Health Plans coverage criteria, requirements, and coding guidance for solid organ transplantation services and related devices when benefits are provided under a member's contract; applies to multiple participating organizations listed by the plan.

Policy Summary

PayerJohns Hopkins Health Plans

PolicySolid Organ Transplantation — Coverage Criteria

Policy CodePolicy CMS19.05

Change TypeOperational/documentation revisions

Effective Date04/01/2026

Last ReviewJan 20, 2026

Next Review Date

Key ActionObtain prior authorization before listing a patient for organ allocation and include the Transplant Program Listing Committee decision in the submission.

SourceLink

POLICY UPDATE CHANGES

Removed language stating Medical Director review is required for determining medical necessity.

Removed excessive requirements for clinical documentation, such as details of pre-transplant evaluation.

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Modifiedjohns_hopkins_health_plansPolicy CMS19.05

Solid Organ Transplantation — Coverage Criteria

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Sign up for johns_hopkins_health_plans Policy CMS19.05 alerts

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Policy Summary

PayerJohns Hopkins Health Plans

PolicySolid Organ Transplantation — Coverage Criteria

Policy CodePolicy CMS19.05

Change TypeOperational/documentation revisions

Effective Date04/01/2026

Last ReviewJan 20, 2026

Next Review Date

Key ActionObtain prior authorization before listing a patient for organ allocation and include the Transplant Program Listing Committee decision in the submission.

SourceLink

POLICY UPDATE CHANGES

Removed language stating Medical Director review is required for determining medical necessity.

Removed excessive requirements for clinical documentation, such as details of pre-transplant evaluation.

All transplantspreauthorization requirement

RequiredOPTN membership requirement

~40+procedure and HCPCS codes listed

11policy pages

Coverage Criteria for Solid Organ Transplantation

General Solid Organ Transplant Coverage

Covered when ALL of the following are met:

Solid organ transplant general criteria: 1. Prior authorization is obtained before listing the potential transplant recipient for organ allocation. 2. The transplant procedure is performed at a designated transplant facility as determined by the member's contract. 3. The transplant program for the requested organ is an active OPTN member for that specific organ. 4. Clinical documentation submitted for transplant listing preauthorization includes: a) Transplant Program Listing Committee (or equivalent) documented the decision to proceed with listing; and b) Transplant Program–specific inclusion and exclusion criteria demonstrating the member meets the program's medical, surgical, and psychosocial requirements. 5. Continued listing requires documented reevaluation by the Transplant Program Listing Committee (or equivalent) that the member remains eligible based on the program-specific wait list criteria (frequency per center protocol). 6. The member may be registered at multiple transplant programs within the same or different Donation Service Areas (DSAs).

Do not flatten program-specific suitability; transplant center–specific rules and frequency of reevaluation are determined by the transplant program.

Donor Expenses and Heart Device Coverage

Covered when ALL of the following are met:

Donor and device coverage: 1. Transplantation donor expenses are covered under the transplant recipient's benefit plan when benefits are provided under the member's contract. 2. SynCardia Temporary Total Artificial Heart (TAH) is medically necessary when used as a temporary bridge to heart transplantation when: a) the member is awaiting heart transplantation, AND b) the member is at imminent risk of death due to biventricular heart failure. 3. The Freedom Portable Driver for the SynCardia TAH is covered when: a) the member's condition allows discharge to await heart transplant at home, AND b) the member and caregiver(s) have received sufficient education on device management as documented by the care team.

Device coverage is limited to specified clinical situations (bridge to transplant and home management with documented education).

The list of CPT and HCPCS codes in this policy is provided for informational purposes only. Inclusion of a code does not imply coverage, and the presence or absence of a code here is not a guarantee of reimbursement. Benefit coverage for any service is determined by the member's specific benefit plan document and applicable laws.

Revision summary: the policy language has been updated to remove requirements that a Medical Director review is mandatory for prior authorization determinations. Prior authorization may be granted based on utilization management (UM) nurse review, and excessive requirements for detailed pre-transplant evaluation documentation have been removed from documentation expectations.

Transplant candidate suitability and contraindications are determined primarily by the transplant program and can vary between centers. A candidate who is unacceptable at one transplant center may be acceptable at another because programs may apply different medical and non-medical criteria (for example, varying sobriety requirements for alcohol-related liver disease).

Procedure and Billing Codes

Informational CPT CodesCPT

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor.
32851	Lung transplant, single; without cardiopulmonary bypass.
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.
33927	Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy.
33928	Removal and replacement of total replacement heart system (artificial heart).
33930	Donor cardiectomy-pneumonectomy (including cold preservation).
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy.
33940	Donor cardiectomy (including cold preservation).

1–10 of 19

1/2

Procedure CPT CodesCPTCovered

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver donor.
32851	Lung transplant, single; without cardiopulmonary bypass.
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.
33927	Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy.
33928	Removal and replacement of total replacement heart system (artificial heart).
33930	Donor cardiectomy-pneumonectomy (including cold preservation).
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy.
33940	Donor cardiectomy (including cold preservation).

1–10 of 33

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HCPCS CodesHCPCSCovered

S2053	Transplantation of small intestine and liver allografts.
S2054	Transplantation of multivisceral organs.
S2055	Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor.
S2060	Lobar lung transplantation.
S2061	Donor lobectomy (lung) for transplantation, living donor.
S2065	Simultaneous pancreas kidney transplantation.
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; procurement, transplantation, and related complications; includes comprehensive services.

inv-09: EPTS score priority

EPTS priority thresholdCandidates with Estimated Post Transplant Survival (EPTS) scores of 20% or less receive priority offers for kidneys from donors with similar KDPI before other candidates.

EPTS score rangeEPTS scores range from 0% to 100% and are assigned to adult kidney candidates.

EPTS componentsEPTS is based on: time on dialysis, current diagnosis of diabetes, prior solid organ transplants, and candidate age.

inv-10: Policy pages

Document page countPolicy pages indicated through page 11 (examples: pages shown as 4 of 11, 7 of 11, 8 of 11, 10 of 11).

Effective and approval dates on pages

Provider Actions and Authorization Requirements

Prior Authorization

Listing preauthorization required

Prior authorization is required before listing a potential transplant recipient for organ allocation. Continued listing also requires documented reevaluation by the Transplant Program Listing Committee.

All solid organ transplants require prior authorization before listing for organ allocation.
Continued listing requires documented reevaluation by the transplant program listing committee.

Prior Authorization

Prior authorization review pathway

Prior authorization determinations may be completed after utilization management (UM) nurse review; Medical Director review is not required per the revision history.

Operational change: prior authorization may be granted based on UM nurse review.
Removed requirement for Medical Director review for determining medical necessity.

Transplant Candidate Listing Criteria

Candidate Listing Criteria

Transplant candidate suitability is determined by transplant program-specific medical, surgical, and psychosocial criteria aligned with OPTN policies; program listing committee documentation is required.

Candidate listing requirements: 1. The Transplant Program Listing Committee (or equivalent) documents the decision to proceed with listing the candidate for organ allocation. 2. The transplant program’s inclusion and exclusion criteria demonstrate the candidate meets medical, surgical, and psychosocial requirements for the specific organ as defined by the transplant program and aligned with OPTN policies. 3. If suitability criteria are not met, the transplant program must provide the rationale for exception to support decision-making. 4. Frequency of reevaluation and continued listing is determined by each transplant center's organ-specific protocols, and continued listing requires a documented reevaluation summary from the listing committee indicating ongoing eligibility. 5. Transplant suitability and contraindications may vary by center (for example, differing sobriety rules for alcohol-related liver disease); a candidate unacceptable at one center may be acceptable at another.

Preauthorization review requires submission of the listing committee decision and program-specific criteria; excessive pre-transplant evaluation details are not required for UM decision-making.

Contraindications and Suitability Considerations

Contraindications to transplantation and assessments of suitability are often program-specific and may include both medical and non-medical factors. Examples of these factors include estimated life expectancy, injurious behaviors, adherence concerns, adequacy of social and financial support, intellectual disability, and specific medical measures such as comorbid conditions, lab values, functional status, ventilatory or support device needs. Center-specific rules may therefore determine listing eligibility or contraindications for an individual member.

Pre-authorization Evaluation Requirements

Documentation Required

EVALUATION REQUIREMENTS

Preauthorization review requires documentation of the Transplant Program Listing Committee decision and the transplant program–specific inclusion/exclusion criteria demonstrating candidate eligibility.

Submit the Listing Committee decision and program-specific criteria to support the UM review.

Transplant Center and Facility Requirements

Note

CENTER REQUIREMENTS

Transplants must be performed at a designated transplant facility as determined by the member's contract, and the transplant program must be an active OPTN member for the specific organ; centers must meet applicable regulatory and program requirements.

Perform the transplant at a facility designated in the member's contract.
Ensure the transplant program is an active OPTN member for the organ being transplanted.

Post-Transplant Inpatient Coverage and Monitoring

inv-29: Inpatient transplant admissions

Pre-authorization requirement for inpatient admissionsAll inpatient admissions related to transplant require pre-authorization.

Monitoring of adherenceAdherence to pre-authorization requirements may be monitored via post-payment data analysis and/or medical review audits.

Coding disclaimer contextCoding lists are informational and inclusion does not imply coverage; benefit coverage determined by the member's specific benefit plan document and applicable laws.

Key Definitions

inv-20: Donation Service Area (DSA) definition

DefinitionDonation Service Area (DSA): The geographic area designated by CMS that is served by one organ procurement organization (OPO), one or more transplant hospitals, and one or more donor hospitals (OPTN, 2025a).

Use in policyMultiple listing and program acceptance decisions may occur across DSAs; transplant programs choose whether to accept multiple registrations.

Source authorityDefinition sourced to OPTN (2025a) and CMS designation referenced in policy definitions.

inv-21: Estimated Post Transplant Survival Score (EPTS) definition

DefinitionEstimated Post Transplant Survival Score (EPTS): Score assigned to adult kidney candidates based on time on dialysis, current diagnosis of diabetes, prior solid organ transplants, and candidate age; range 0%–100%.

Priority allocation note

Background and Operational Context

OPTN/UNOS centrally manage organ allocation using computerized match-run algorithms tailored to each organ, while individual transplant centers evaluate candidate suitability using program-developed medical and non-medical criteria. Transplant programs must meet regulatory and certification requirements and maintain trained interdisciplinary teams. Although allocation is centralized, transplant centers perform the clinical assessment of candidates and make the final listing decision, and the Transplant Program Listing Committee's documented decision is required for prior authorization and for continued listing decisions.

Policy Summary

PayerJohns Hopkins Health Plans

PolicySolid Organ Transplantation — Coverage Criteria

Policy CodePolicy CMS19.05

Change TypeOperational/documentation revisions

Effective Date04/01/2026

Last ReviewJan 20, 2026

Next Review Date

Key ActionObtain prior authorization before listing a patient for organ allocation and include the Transplant Program Listing Committee decision in the submission.

SourceLink

On This Page

Effective date 04/01/2026; Approval date 01/20/2026 are shown in header/footer on multiple pages.

Supersedes and original datesSupersedes date 04/01/2025; Original date 03/01/2003 appear in document pagination headers.

Documentation Required

Transplant Program Listing Committee decision required

Submit clinical documentation showing the Transplant Program Listing Committee (or equivalent) documented the decision to proceed with patient listing for organ allocation.

Include the Transplant Program Listing Committee decision to proceed with listing.
Provide transplant program-specific inclusion/exclusion criteria demonstrating the member meets medical, surgical, and psychosocial requirements.

Documentation Required

Include program-specific criteria with submission

Ensure transplant program-specific inclusion and exclusion criteria are provided to demonstrate the member meets the program’s medical, surgical, and psychosocial criteria when requesting preauthorization.

Include program-specific inclusion/exclusion criteria with the preauthorization submission.
Coding information provided in policy is informational; include clinical program documentation for UM review.

Documentation Required

Preauthorization submission requirements

Clinical documentation for transplant listing preauthorization must include the Transplant Program Listing Committee decision and the transplant program’s inclusion/exclusion criteria that demonstrate the member meets the program’s medical, surgical, and psychosocial criteria.

If suitability criteria are not met, provide the rationale for exception.
Do not include excessive pre-transplant evaluation detail — the program's documented decision is sufficient.

Documentation Required

Transplant Program decision sufficiency

The Transplant Program's documented decision to proceed with listing for organ allocation is sufficient for utilization management decision-making; excessive pre-transplant evaluation details are not required.

UM decision-making may rely on the program’s documented Listing Committee decision.
Removed requirement for detailed pre-transplant evaluation in documentation expectations.

Denial Risk

Denial risk if prior authorization not obtained

Failure to obtain prior authorization before listing for organ allocation may trigger denial of coverage for the transplant listing.

Obtain prior authorization before listing to avoid potential denial of coverage.

Denial Risk

Documentation risk for missing program decision

Lack of a documented Transplant Program decision to proceed with listing may lead to denial; prior authorization decisions may be based on program documentation and UM nurse review.

Ensure the Listing Committee decision is documented and submitted with the preauthorization request.
Recognize UM nurse review may be used for prior authorization determinations.

Candidates with EPTS scores of 20% or less receive priority offers for kidneys from donors with similar KDPI before other candidates.

ApplicabilityAssigned to all adult candidates on the kidney waiting list to inform kidney allocation decisions.

inv-22: Kidney Donor Profile Index (KDPI) definition

DefinitionKidney Donor Profile Index (KDPI): A donor-based index that combines donor factors into a single number summarizing the likelihood of graft failure after a deceased donor kidney transplant.

InterpretationLower KDPI scores are associated with longer estimated graft function; higher KDPI scores with shorter estimated function (example: KDPI 20% expected longer function than 80% of recovered kidneys).

Relation to EPTSKDPI is used in allocation such that kidneys with similar KDPI are offered preferentially to candidates with low EPTS scores (≤20%).

inv-23: Match Run / Wait List definition

DefinitionMatch Run: An organ-specific algorithm that filters and ranks waiting list candidates for potential donors and is used to generate ordered candidate lists for allocation (also used for kidney paired donation exchanges).

Waitlist statusMatch runs incorporate candidate data (e.g., active vs inactive status) and donor characteristics to determine offer sequencing; inactive candidates do not receive offers.

Operational sourceDefinition and operational use cited to OPTN (2025a) as described in policy definitions and match-run explanation.

inv-24: Multivisceral transplant

DefinitionMultivisceral transplant: Transplantation involving multiple abdominal organs (examples include small intestine and liver) as described in HCPCS codes S2053 (transplantation of small intestine and liver allografts) and S2054 (transplantation of multivisceral organs).

Related HCPCS codesHCPCS S2053 = Transplantation of small intestine and liver allografts; S2054 = Transplantation of multivisceral organs; S2055 = Harvesting of donor multivisceral organs.

Coverage noteHCPCS codes listed are informational; inclusion does not alone determine coverage—benefit coverage is subject to the member's plan document.