Currentpartners_health_managementPolicy NC.CP.MP.132

Clinical Policy: Heart-Lung Transplant

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Medical necessity criteria and contraindications for heart-lung transplantation for members of the health plan, including adult and pediatric indications and disease severity requirements.

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Heart-Lung Transplant

Policy CodePolicy NC.CP.MP.132

Change TypeAnnual review — no material clinical changes

Effective Date

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization and submit required clinical documentation supporting end‑stage heart and end‑stage lung disease, disease severity, life‑expectancy estimate, and absence of listed contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18adult age threshold

<18pediatric age group

≥2 yrsrequired life expectancy

GFR<40renal contraindication

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Currentpartners_health_managementPolicy NC.CP.MP.132

Clinical Policy: Heart-Lung Transplant

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Medical necessity criteria and contraindications for heart-lung transplantation for members of the health plan, including adult and pediatric indications and disease severity requirements.

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Heart-Lung Transplant

Policy CodePolicy NC.CP.MP.132

Change TypeAnnual review — no material clinical changes

Effective Date

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18adult age threshold

<18pediatric age group

≥2 yrsrequired life expectancy

GFR<40renal contraindication

median survival (adult era)

Coverage Criteria for Heart‑Lung Transplant

Medically necessary criteria for heart-lung transplant

Covered when ALL of the following are met:

Overall: Member has end-stage heart and end-stage lung disease due to one of the specified indications; meets disease severity and life-expectancy criteria; and does not have listed contraindications.

Indications - Adults (age ≥ 18): One of the following adult indications is present: irreversible primary pulmonary hypertension with severe heart failure; nonspecific idiopathic severe pulmonary fibrosis; Eisenmenger complex with irreversible pulmonary hypertension and heart failure; cystic fibrosis with severe heart failure; chronic obstructive pulmonary disease with heart failure; emphysema with severe heart failure; pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure; congenital heart disease meeting specified subcriteria (including single ventricle/Fontan patients with symptomatic HF and reduced systolic function; symptomatic HF with preserved systolic function and abnormal systemic ventricular filling pressures; lymphatic abnormalities refractory to intervention; cirrhosis or CKD due to chronically elevated central venous pressures; palliation to a shunted circulation with prohibitive risk for further single ventricle palliation; cyanotic heart disease with severe atrio-ventricular valve regurgitation and prohibitive risk for repair; pulmonary atresia with intact ventricular septum and right ventricular dependent coronary circulation with atresia of at least one aortocoronary ostium); severe coronary artery disease or cardiomyopathy with irreversible pulmonary hypertension; right ventricular failure with objective evidence of RV fibrosis or infarction or refractory LV failure; heart or ventricular arrhythmias or HF refractory to medical/interventional/device therapies; reactive pulmonary hypertension at risk of developing fixed irreversible PVR.age ≥ 18

See chunks 2-4 for full adult indication list.

Indications - Pediatrics (age < 18): One of the following pediatric indications is present: Eisenmenger syndrome; heart re-transplant; lung re-transplant; primary pulmonary hypertension; pulmonary vascular disease; restrictive cardiomyopathy; congenital heart disease meeting specified subcriteria (including single ventricle/Fontan patients with symptomatic HF and reduced systolic function; symptomatic HF with preserved systolic function and abnormal systemic ventricular filling pressures; lymphatic abnormalities refractory to interventions; cirrhosis or CKD due to chronically elevated central venous pressures; palliation to a shunted circulation with prohibitive risk for further single ventricle palliation; cyanotic heart disease with severe atrio-ventricular valve regurgitation and prohibitive risk for repair; pulmonary atresia with intact ventricular septum and right ventricular dependent coronary circulation with atresia of at least one aorto-coronary ostium); neonatal hypoplastic left heart syndrome with high-risk features.age < 18

See chunks 2-4 for pediatric specifics.

Disease severity and prognosis: Meets staging criteria: adults with NYHA Class III or IV OR pediatrics with AHA Stage C or D; AND estimated life expectancy in the absence of cardiopulmonary disease is ≥ 2 years.NYHA III/IV or AHA Stage C/D; life expectancy ≥ 2 years

Chunk 4

Contraindications: No listed contraindications are present (see exclusions/contraindications section of the policy).

Chunk 5 referenced in brief for contraindication list.

Coverage is excluded when any of the following contraindications are present: active, potentially life‑threatening malignancy (unless transplant is performed for cure); active extrapulmonary or disseminated infection; active tuberculosis infection; septic shock; acute renal failure with rising creatinine or on dialysis with low likelihood of recovery; acute liver failure or cirrhosis with portal hypertension or significant synthetic dysfunction (unless being considered for multi‑organ transplant); recent stroke, acute coronary syndrome, or myocardial infarction within 30 days; glomerular filtration rate < 40 mL/min/1.73 m2 (unless multiorgan transplant is planned); progressive cognitive impairment; other severe uncontrolled medical conditions expected to limit survival after transplant; current ongoing acute allograft rejection when re‑transplantation is requested; less than 6 months since primary transplant when retransplantation is requested; inability to adhere to the required post‑transplant regimen despite caregiver support; and active substance use or dependence without convincing evidence of sustained risk‑reduction/abstinence (history generally requires documentation of ≥6 months abstinence).

Coverage and authorization for heart‑lung transplantation are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable state and federal requirements. The Health Plan determines the effective date of this clinical policy and retains the right to amend or withdraw the policy; where state Medicaid provisions conflict with this policy, state Medicaid provisions prevail.

Services are not medically necessary when any of the listed contraindications are present. Additionally, heart‑lung transplantation is not medically necessary when lung transplantation alone would restore right ventricular function (i.e., an isolated lung transplant suffices to correct the cardiac consequence).

Candidate Selection

Candidate selection

Candidates must meet indication, severity, and life-expectancy requirements and lack contraindications.

Age-based indication: Adults (≥18) and children (<18) have separate enumerated indications; see policy for detailed congenital heart disease and Fontan-specific subcriteria.

Chunks 2-4

Severity and prognosis: Meets one of the staging criteria: adults NYHA Class III or IV OR pediatrics AHA Stage C or D; AND life expectancy in the absence of cardiopulmonary disease ≥ 2 years.NYHA III/IV or AHA Stage C/D; life expectancy ≥ 2 years

Chunk 4

Absence of contraindications: No contraindications from the policy’s exclusions are present (examples include active potentially life‑threatening malignancy, active extrapulmonary or disseminated infection, active tuberculosis, septic shock, acute renal failure or GFR < 40 mL/min/1.73m2 unless multiorgan transplant, acute liver failure or cirrhosis with portal hypertension or synthetic dysfunction unless multiorgan transplant, recent stroke/ACS/MI within 30 days, progressive cognitive impairment, inability to adhere to regimen, active substance use without documented abstinence).

Contraindications

Key contraindications that typically preclude approval include: active potentially life‑threatening malignancy (unless transplant for cure); active extrapulmonary or disseminated infection or active tuberculosis; septic shock; acute renal failure with rising creatinine or dialysis with low likelihood of recovery; and GFR < 40 mL/min/1.73 m2 unless the candidate is being considered for multiorgan transplant. These conditions, along with recent major cardiovascular or cerebrovascular events, uncontrolled comorbidities, progressive cognitive impairment, inability to adhere to therapy, and active substance use without demonstrated abstinence, are specified as exclusions in the policy.

Evaluation and Pre-Transplant Assessment

Documentation Required

Evaluate and document NYHA/AHA stage and life expectancy

Assess and document disease severity and prognosis before authorization: confirm adult members meet NYHA Class III or IV or pediatric members meet AHA Stage C or D, and provide an estimate that life expectancy in the absence of cardiopulmonary disease is ≥ 2 years. Include relevant congenital-specific evaluations when applicable (e.g., Fontan/CHD subcriteria).

Document NYHA Class III or IV for adults (Table 1) or AHA Stage C or D for children (Table 2).
Provide a documented life-expectancy estimate ≥ 2 years in the absence of cardiopulmonary disease.
Include congenital heart disease–specific assessments when indicated (per enumerated subcriteria).

Prior Authorization

Obtain prior authorization and follow cited guidelines/plan procedures

Follow Health Plan prior-authorization procedures and referenced guidelines when requesting coverage and performing evaluations: prior authorization is required per plan for heart–lung transplantation and providers must follow the Health Plan's administrative procedures and cited professional guidance (e.g., ISHLT) for required evaluation steps.

Provider Actions & Documentation

Prior Authorization

Prior authorization required for specified transplant procedure codes

Obtain prior authorization before performing heart‑lung transplantation procedures and include the clinical criteria and contraindication assessment in the submission.

Include documentation supporting medical necessity and contraindication review with the authorization request.
Referenced procedure codes: CPT 33930, 33933, 33935 and HCPCS S2152 (informational; inclusion does not guarantee coverage).

Prior Authorization

Prior authorization required — follow Health Plan determination

Ensure any required prior authorization is obtained per the member's Health Plan; authorization and coverage are effective as determined by the Health Plan and subject to plan terms.

Verify the member’s plan requirements and follow Health Plan authorization procedures and timelines.
Coverage effectiveness and administrative rules are determined by the Health Plan and applicable state/federal requirements.

Procedure and Billing Codes

Referenced procedure codesCPT|HCPCS

33930	Donor cardiectomy-pneumonectomy, including cold preservation
33933	Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation.
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition

Glomerular filtration rate (GFR) contraindication — INV-06

GFR thresholdGlomerular filtration rate (GFR) < 40 mL/min/1.73 m2 is a contraindication to heart‑lung transplantation unless the member is being considered for multiorgan transplant.

Context of contraindicationListed among explicit contraindications that preclude approval for transplant when present.

ExceptionThreshold does not apply when multiorgan transplant is being considered (multiorgan exception explicitly noted).

Post‑Transplant Coverage

Heart‑lung transplant surgery and procurement codes — INV-24

CPT codes referenced33930 — Donor cardiectomy-pneumonectomy, including cold preservation; 33933 — Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation; 33935 — Heart-lung transplant with recipient cardiectomy-pneumonectomy.

HCPCS code referencedS2152 — Solid organ(s) procurement, transplantation, and related complications (global procurement/transplant bundle) as described in policy coding section.

Coding guidanceCodes are referenced for informational purposes; inclusion or exclusion of codes does not guarantee coverage — providers should reference current coding manuals prior to claim submission.

Post‑transplant coverage governance — INV-25

Governing documentsPost‑transplant coverage and benefits are governed by the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance) and applicable state and federal requirements.

Background

Heart‑lung transplantation is reserved for selected patients with simultaneous end‑stage heart and lung disease. Common indications cited in policy and practice include complex congenital heart disease with Eisenmenger physiology, primary pulmonary hypertension with severe right‑sided failure, and cystic fibrosis with advanced cardiopulmonary compromise. The procedure is infrequent relative to single‑organ transplantation because of donor organ availability and evolving medical therapies; candidate selection and expected outcomes are guided by ISHLT criteria and registry data referenced in the policy.

Definitions and Clinical Staging

NYHA Class III/IV definitions — INV-16

NYHA Class IIIMarked limitation of physical activity; comfortable at rest; less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

NYHA Class IVInability to carry on any physical activity without discomfort; symptoms of cardiac insufficiency or angina may be present even at rest.

Use in criteriaAdults must meet NYHA Class III or IV as part of disease severity requirements for transplant candidacy.

AHA Stage C/D (pediatrics) definitions — INV-17

AHA Stage C (pediatrics)Symptomatic heart failure with current or prior symptoms of heart failure.

AHA Stage D (pediatrics)Advanced heart failure with symptoms that interfere with daily life functions or result in recurrent hospitalizations despite guideline-directed medical therapy.

Center Requirements

Note

Center requirements — see ISHLT guidance; not specified in policy

Center-specific accreditation or volume requirements are not detailed in this policy; the document references ISHLT listing criteria and best practice recommendations for center selection and standards.

Refer to ISHLT listing criteria and professional guidance for center-level best practices and listing requirements.
Policy does not stipulate specific center accreditation or minimum volumes within the cited chunks.

Revision History

2026-04-01policy_reviewLatest

Policy last reviewed on 2026-04-01 with next review scheduled for 2026-04-01 per document metadata.

2016copyright_notice

Policy Summary

Payerpartners_health_management

PolicyClinical Policy: Heart-Lung Transplant

Policy CodePolicy NC.CP.MP.132

Change TypeAnnual review — no material clinical changes

Effective Date

Last ReviewApr 1, 2026

Next Review DateApr 1, 2026

SourceLink

On This Page

Contraindications enumerated in policy exclusions (see chunks referenced in brief).

Required documentation: Clinical documentation must support diagnoses of end‑stage heart and end‑stage lung disease, disease severity staging (NYHA Class III/IV for adults; AHA Stage C/D for pediatrics), life expectancy estimate ≥ 2 years without cardiopulmonary disease, and evaluation demonstrating absence of listed contraindications.

Chunks 2,4 and brief documentation requirements.

Obtain prior authorization as required by the Health Plan before performing transplant procedures.
Submit clinical documentation that demonstrates indications, staging (NYHA III/IV or AHA C/D), life-expectancy estimate, and absence of listed contraindications.
Refer to cited guidelines (such as ISHLT) and the Health Plan’s procedures for detailed evaluation steps and documentation requirements.

Step Therapy

Step therapy — not applicable

Step therapy requirements do not apply to heart‑lung transplant authorization; focus is on transplant candidacy and contraindication review rather than sequential trials of therapy.

Do not submit step-therapy trial documentation as a substitute for transplant candidacy evaluation.

Documentation Required

Required clinical documentation to support authorization

Include clinical documentation that supports end‑stage heart and end‑stage lung disease, disease severity staging (NYHA Class III/IV for adults; AHA Stage C/D for pediatrics), estimated life expectancy ≥ 2 years without cardiopulmonary disease, and absence of listed contraindications.

Diagnosis and indication details matching policy adult or pediatric lists.
Objective staging documentation (NYHA or AHA) and life‑expectancy estimate.
Documentation addressing each potential contraindication and rationale if borderline.

Denial Risk

Contraindications that may preclude approval — triggers for denial

Document and address policy-listed contraindications; the presence of these conditions may preclude approval and lead to denial of coverage.

Active potentially life‑threatening malignancy (except when transplant is for cure).
Glomerular filtration rate < 40 mL/min/1.73 m2 unless being considered for multiorgan transplant.
Active extrapulmonary or disseminated infection, active tuberculosis, septic shock.
Active substance use or dependence without documentation of abstinence or risk‑reduction (typically ≥ 6 months).
Acute renal failure on dialysis with low likelihood of recovery; acute liver failure or cirrhosis with portal hypertension unless multiorgan transplant.

Billing Rule

Coverage subject to plan terms, exclusions, and limitations

Coverage determinations and the administration of benefits for transplant services are subject to all terms, conditions, exclusions, and limitations of the member’s coverage documents and applicable legal/regulatory requirements.

Verify evidence of coverage, certificate of coverage, policy, or contract terms prior to authorization and billing.
State Medicaid provisions supersede this policy where applicable.

Note

No provider-action content specified for this placeholder.

Plan-determined effectivenessThis clinical policy is effective as of the date determined by the Health Plan; posting date may not equal the effective date.

Regulatory precedenceWhen state Medicaid provisions conflict with this policy, state Medicaid coverage provisions take precedence.

Use in criteriaPediatric candidates must meet AHA Stage C or D as part of disease severity requirements for transplant candidacy.

ISHLT pediatric consensus citation (2025) — INV-18

CitationInternational Society for Heart and Lung Transplantation Consensus Statement on the Referral and Selection of Pediatric Lung Transplant Candidates. J Heart Lung Transplant. 2025;44(12):e133-e176. doi:10.1016/j.healun.2025.08.005

Role in policyCited as the referenced guidance for referral and selection of pediatric lung transplant candidates within this clinical policy.

Recommendation useRefer to the 2025 ISHLT consensus for pediatric-specific listing and selection considerations when evaluating pediatric candidates for transplant.