Kaiser Permanente heart transplant Coverage

Coverage Criteria — Indications and Contraindications

inv-01: Indications for heart transplant (Initial)

Covered when ALL of the following are met

Primary indications for heart transplant: End-stage heart disease not correctable by medical or other surgical therapies AND one or more of the following: NYHA functional class III or IV; low peak VO2 (<14 mL/kg/min if not on a beta blocker or <12 mL/kg/min if on a beta blocker, or <50% of age‑predicted maximum); cardiac index ≤2 L/min/m2; inability to wean from mechanical circulatory or inotropic support; specific cardiomyopathies such as transthyretin (TTR) amyloid or AL amyloidosis without significant extra‑cardiac involvement; or refractory life‑threatening arrhythmias.See VO2 and cardiac index thresholds in nodes

Applies to non‑Medicare members per document

inv-02: Contraindications / Not medically necessary

Not medically necessary or contraindicated when ANY of the following absolute conditions are present

Absolute contraindications / Not medically necessary: Uncontrollable active infection; recent substance abuse without documented abstinence and evaluation (commonly 6 months); active or significant psychiatric/psychological conditions or significant irreversible neurologic dysfunction that would prevent adherence; severe uncontrolled hypertension; clinically significant vascular disease not correctable by intervention; pulmonary hypertension not reversible with maximum tolerated medical therapy (Adults: PVR >4–6 Wood units or transpulmonary gradient >15 mm Hg; Children: PVR >9 Wood units); severe pulmonary or hepatic disease despite optimal treatment of heart failure; severe renal dysfunction (creatinine clearance <34 mL/min or GFR ≈30 mL/min after optimal treatment); evidence of cachexia or malnutrition (BMI <19 kg/m2 or <80% ideal body weight); diabetes with severe end‑organ damage; autoimmune disease with multi‑organ involvement; acute pulmonary embolus; active peptic ulcer disease; severe symptomatic osteoporosis; age over 70 (generally a contraindication though carefully selected patients may be considered); AL amyloidosis with significant extra‑cardiac manifestations; other comorbid conditions that would limit life expectancy or quality of life.See PVR, renal, and BMI thresholds

Candidates with certain conditions may be considered only after further specialty evaluation or exception

Transplantation should be considered only when there is clear evidence that cardiac transplant provides a clinical benefit for the patient. For heart transplant this means the patient has end-stage heart disease not correctable by medical or other surgical therapies and meets physiologic criteria such as NYHA class III or IV, a demonstrably low peak VO2 (see thresholds), a low cardiac index, inability to wean from mechanical or inotropic support, or specific cardiomyopathies (for example transthyretin or select AL amyloidosis without significant extra-cardiac involvement). The transplant recommendation applies in conjunction with the general principles for candidate selection (early referral, demonstrated adherence, social support, and ability to travel to an approved transplant center).

Common reasons a candidate will be deemed not appropriate for transplant include active or uncontrolled infection, recent substance abuse without documented abstinence and program evaluation, demonstrable poor adherence or insufficient social support, and significant comorbid conditions that limit life expectancy or functional benefit from transplant. Additional exclusionary conditions include severe uncontrolled hypertension, irreversible pulmonary hypertension, advanced renal, hepatic or pulmonary disease despite optimal treatment, cachexia or malnutrition (see BMI thresholds), and other medical or neurologic conditions that would preclude successful outcomes.

inv-16: General principles for transplant candidates

Candidate selection and general principles

General candidate requirements: Early referral for transplant evaluation when clinical parameters indicate end‑stage or life‑threatening heart disease; candidates must be free from tobacco use for six months for thoracic organ transplantation; free from alcohol and other substance abuse for six months with evaluation by a substance abuse program; have adequate social support and caregivers able to travel on short notice to a KP approved transplant Center of Excellence; demonstrate a proven record of adherence to medical treatment and completion of pre‑transplant evaluation; and be willing and able to travel on short notice and return for treatment of complications.6 months abstinence in many cases

All candidates must be continuously re‑evaluated for indications and contraindications; exceptions may be made case‑by‑case

Candidate Selection Principles

inv-16: General principles for transplant candidates

Candidate selection and general principles

All candidates must be continuously re‑evaluated for indications and contraindications; exceptions may be made case‑by‑case

Absolute and Relative Contraindications

Absolute contraindications include uncontrollable active infection. Substance abuse is a contraindication unless the candidate has been abstinent for six (6) months and evaluated by a substance abuse program demonstrating low recidivism risk. Other absolute or relative contraindications include significant irreversible neurologic dysfunction or active psychiatric disease that interferes with adherence, pulmonary hypertension not reversible with maximal medical therapy (see PVR thresholds), severe end‑organ disease (renal, hepatic, pulmonary) after optimal treatment, cachexia or malnutrition (for example BMI <19 kg/m2), diabetes with severe end‑organ damage, multi‑organ autoimmune disease, active peptic ulcer disease, severe symptomatic osteoporosis, and generally advanced age (>70 years) except in carefully selected cases.

Evaluation and Re-evaluation Requirements

Prior Authorization

Prior Authorization Required

Authorization is required prior to scheduling transplant procedures. Submit a prior authorization request that includes relevant transplant procedure codes and all required documentation. Do not schedule the transplant until authorization is received.

Provider must request prior authorization for transplant procedure codes (include CPT/HCPCS codes on the request).
Authorization request must include documentation listed in the documentation callout below.

Documentation Required

Required Documentation & Therapy Failure

Provide documentation to support medical necessity for transplant evaluation and demonstrate that conservative/medical therapies have failed when applicable prior to transplant listing.

Therapy failure prerequisite: Document prior appropriate medical or device therapy and evidence of failure or contraindication to those therapies when required by the specific organ transplant criteria.

Provider Actions, Authorization & Documentation

Prior Authorization

Verify prior authorization for transplant procedure codes

Certain heart transplant procedure CPT codes are listed in the policy; verify authorization requirements for the specific code and member plan using the Pre-authorization Code Check.

Covered CPT codes listed include 33940, 33944, and 33945.

Step Therapy

Require failure of corrective medical/surgical therapies before transplant

Transplant should be considered only after medical and other surgical therapies are not corrective; candidates must have refractory end‑stage disease meeting the physiologic criteria listed in the policy.

Policy states end‑stage heart disease must be “not correctable by medical or other surgical therapies.”
Physiologic criteria include NYHA class III–IV, low VO2 maximum, low cardiac index, inability to wean from support, or specific cardiomyopathies.

Coding, Clinical Thresholds, and Measures

Covered CPT Codes (listed)CPTCovered

33940	Donor cardiectomy (including cold preservation)
33944	Backbench standard preparation of cadaver donor heart allograft prior to transplantation
33945	Heart transplant with or without recipient cardiectomy

Renal function and VO2

VO2 maximum thresholdsPeak VO2 <14 mL/kg/min for patients not on a beta blocker; <12 mL/kg/min for patients on a beta blocker; or <50% of age-predicted maximum

Renal function contraindicationCreatinine clearance <34 mL/min or GFR ≈30 mL/min after optimal treatment of heart failure

Cardiac index criterionCardiac index ≤ 2 L/min/m2 may support indication for transplant

Pulmonary vascular resistance (PVR)

Adult PVR contraindicationPulmonary vascular resistance >4–6 Wood units or transpulmonary gradient >15 mm Hg

Pediatric PVR thresholdPulmonary vascular resistance >9 Wood units in children

Key Definitions and Clinical Thresholds

Peak VO2 maximum

VO2 maximum absolute thresholds<14 mL/kg/min (off beta blocker) or <12 mL/kg/min (on beta blocker)

Percent predictedLess than 50% of age-predicted maximum may indicate severe limitation

Role in indicationLow peak VO2 is one of the physiologic criteria supporting listing for heart transplant

PVR threshold (adults)

Adult PVR thresholdPulmonary vascular resistance >4–6 Wood units is listed as a contraindication in adults

Transpulmonary gradientTranspulmonary gradient >15 mm Hg is an alternative hemodynamic contraindication

Background and Outcomes

Heart failure can progress to irreversible, end‑stage disease in which the native heart can no longer provide adequate circulatory support. For appropriately selected recipients, reported outcomes after heart transplantation include approximately 80–90% one‑year survival and about 60–70% five‑year survival, supporting the role of transplantation for patients who meet selection criteria and have acceptable peri‑operative risk and post‑transplant support.

80-90%1-year post-transplant survival (reported)

60-70%5-year post-transplant survival (reported)

<14 / <12Peak VO2 thresholds (mL/kg/min) off/on beta blocker

>4-6 WUAdult PVR contraindication (Wood units)

Post-Transplant Coverage and Associated Procedures

Heart transplant procedures and related considerations

Covered heart transplant CPT codes33940: Donor cardiectomy (including cold preservation); 33944: Backbench preparation of cadaver donor heart allograft; 33945: Heart transplant with or without recipient cardiectomy

Combined/staged heart/kidney transplantsSelected patients for combined or staged heart/kidney transplant will be evaluated on a case-by-case basis

Post-transplant outcomesReported one-year survival ~80–90% and five-year survival ~60–70%

Transplant Center and Travel Requirements

Note

Ability to travel to KP approved Transplant Center required

Candidates must be willing and able to travel on short notice to a Kaiser Permanente approved transplant Center of Excellence and be available to return for treatment of complications.

Revision History

2024-12-03policy_reviewLatest

Medical Policy Committee (MPC) review/update recorded on 12/03/2024.

2023-03-07policy_review

MPC review/update recorded on 03/07/2023.

2022-03-01policy_review

OpenPayer

Heart transplant selection and coverage criteria