CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Human Organ and Stem Cell Transplant Coverage Criteria

Defines coverage, reimbursement, claim submission, and coding requirements for human organ and stem cell transplants across Medicaid (excl. EFP), Integrity, and Commercial lines; applies to providers and members involved in transplant care.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHuman Organ and Stem Cell Transplant Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify medical necessity, eligibility, and prior authorization requirements before submitting transplant-related claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10Donor search limit (Commercial)

All LOBCovered donor/recipient services

MultipleEnumerated codes

01/01/2023Most recent action

Coverage Criteria for Transplant Services

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Donor and recipient covered services

When recipient is a member, the following donor and recipient services are covered.

Covered donor/recipient services: Member's donor search expenses (subject to coverage limitations); dental exam prior to kidney transplant; evaluation and preparation of the donor; obtaining and transporting donated organs for the member receiving a transplant; recipient transplant services; member's human leukocyte antigen (HLA) testing; live donor covered services including surgical intervention and recovery services directly related to donation

Donor services for live donors are billed under the recipient's claim per CMS guidance; donor search expenses are subject to limits described elsewhere in the policy

Procedure, Donor/Recipient, and HCPCS/S Codes

Lung and Heart transplant 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.
32855	Backbench standard preparation of cadaver donor allograft to transplantation; unilateral lung.
32856	Backbench standard preparation of cadaver donor allograft to transplantation; bilateral lung.
33930	Donor cardiectomy-pneumonectomy (including cold preservation).
33933	Backbench standard preparation of cadaver donor heart/lung allograft to transplantation.
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy.

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Hematopoietic progenitor cell / bone marrow CPT codesCPTCovered

38204	Management of recipient hematopoietic progenitor cell donor search and cell acquisition.
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic.
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous.
38207	Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage.
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest; without washing, per donor.

Liver transplant and donor hepatectomy CPT codesCPTCovered

47133	Donor hepatectomy (including cold preservation), from cadaver donor.
47135	Liver allotransplantation, orthotopic, or whole, from cadaver or living donor; partial.
47140	Donor hepatectomy, left lateral segment only (living donor).
47141	Donor hepatectomy, total left lobectomy (living donor).
47142	Donor hepatectomy, total right lobectomy (living donor).

Pancreas and Kidney transplant CPT codesCPTCovered

48160	Pancreatectomy; total or subtotal, with autologous transplantation of pancreatic islet cells.
48550	Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation.
48554	Transplantation of 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 to transplantation.
50360	Renal allotransplantation, implantation of graft without recipient nephrectomy.
50365	Renal allotransplantation, implantation of graft with recipient nephrectomy.

Islet, stem cell, and HCPCS/S codesmixedCovered

G0341	Percutaneous islet cell transplant; includes portal vein catheterization and infusion.
G0342	Laparoscopy for islet cell transplant; includes portal vein catheterization and infusion.
G0343	Laparotomy for islet cell transplant; includes portal vein catheterization and infusion.
S2150	Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous; harvesting, transplantation, and related complications; comprehensive.
S2152	Solid organ(s), procurement; transplantation, and related services; deceased or living donor(s).

Transplant procedure and S/G codesmixedCovered

50329	Backbench reconstruction of cadaver or living donor renal allograft to transplantation; ureteral anastomosis, each prior.
50340	Recipient nephrectomy (separate procedure).
50360	Renal allotransplantation, implantation of without recipient nephrectomy graft;
50365	Renal allotransplantation, implantation of with recipient nephrectomy graft;
50370	Removal of transplanted renal allograft.
50380	Renal autotransplantation, reimplantation of kidney.
G0341	Percutaneous islet cell transplant; includes portal vein catheterization and infusion.
G0342	Laparoscopy for islet cell transplant; includes portal vein catheterization and infusion.
G0343	Laparotomy for islet cell transplant; includes portal vein catheterization and infusion.
S2054	Transplantation of multivisceral organs.

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Donor search limit (Commercial)

Donor search limit (Commercial)Maximum of 10 donor searches covered for donors not related by blood (Commercial line of business)

Applies toSearch expenses for donors who are not blood relatives

Line of businessCommercial only (limit specified)

Provider Responsibilities and Billing Requirements

Prior Authorization

Medical Necessity and Eligibility Verification

All services must be medically necessary to qualify for reimbursement. Neighborhood may use LCDs, NCDs, industry-accepted criteria (e.g., InterQual), Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies to determine medical necessity. Providers must verify member eligibility, coverage, and any authorization requirements prior to rendering services.

Verify eligibility, coverage and prior authorization before service.
Medical necessity must be documented in the medical record.

Billing Rule

Claim Submission Format and Requirements

Providers must submit donor charges under the recipient's name and member identification number as required by Neighborhood. Claims must be complete and submitted within contractual timely-filing limits.

Submit all donor charges on the recipient's claim/MBI.
Adhere to contractual timely-filing requirements for claim submission.
01/01/2023 format update: claim submission language and coverage information were updated — follow the revised submission instructions.

Documentation Required

Documentation and Medical Record Requests

Neighborhood reserves the right to request medical records for any billed service. Documentation must support the services billed and demonstrate medical necessity; failure to provide adequate documentation may result in denial.

Maintain complete medical records that support CPT/ICD-10-CM coding and billed services.
Neighborhood may request records to substantiate claims; lack of documentation can lead to denial.

Prior Authorization

Prior Authorization for Transplant Procedures

Providers should verify payer-specific prior authorization requirements for transplant and related procedure codes before performing services.

Confirm prior authorization for listed transplant and donor procurement codes where applicable.
Contact Provider Services at 1-800-963-1001 with questions about authorization or policy details.

Billing Rule

Coding and Billing Standards

Coding must follow AMA CPT, ICD-10-CM, and other applicable coding standards. Billable services are subject to contractual agreements and coverage definitions.

Use current CPT and ICD-10-CM code sets when preparing claims.
Ensure coding and documentation align with Neighborhood coverage and contractual rules.

Key Definitions

Transplant (human organ) definition

DefinitionSurgical removal of a whole or partial organ from one body and transplanting it to another to replace a damaged or failing organ

Donor typesDonors may be living or deceased

Included transplantable organsHeart, kidney (including simultaneous pancreas/kidney and pancreas post-kidney), liver, lung (single and double), bone marrow and stem cells, cornea, intestinal and multivisceral organs, and islet/pancreas procedures

Human organ transplant involves the surgical removal of a whole or partial organ from a living or deceased donor and transplanting it into a recipient to replace a damaged or failing organ. Transplantable organs and tissues referenced in this policy include heart, lung, liver, kidney (including simultaneous pancreas/kidney and pancreas after kidney), pancreas, bone marrow and stem cells, cornea, intestinal and multivisceral organs, and islet/pancreas procedures.

When the recipient is a member, Neighborhood covers services related to the procurement and transplant process — including donor evaluation and preparation, recipient transplant services, HLA testing, and donor surgical and recovery services — provided those services are medically necessary and ordered by a health plan physician.

Detailed Code Listings and Status