OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Modifiedpriority healthPolicy 91272

TRANSPLANTATION OF SOLID ORGANS

Customize your policy alerts

Sign up for priority health Policy 91272 alerts

Get alerted when Policy 91272 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines Priority Health coverage, medical necessity criteria, limitations, and authorization requirements for solid organ transplantation services (evaluation, transplant procedure, donor services, and post-transplant care) for Priority Health members.

Policy Summary

Payerpriority health

PolicyTRANSPLANTATION OF SOLID ORGANS

Policy CodePolicy 91272

Change TypeMaterial deletion and clarifications

Effective DateJun 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit prior authorization using the Solid Organ Transplant prior authorization form and ensure transplant and evaluations occur at a Priority Health approved facility.

SourceLink

POLICY UPDATE CHANGES

Removed length of time (3 month) requirement for patients with a history of substance abuse prior to transplant approval

Updated background and references

1 yearpost-transplant follow-up covered at transplant facility

MELD > 15liver transplant MELD threshold

30 daysdonor medical expenses covered (uninsured)

Not coveredxenotransplantation status

1material deletion recorded

Coverage and Medical Necessity Criteria

General and organ-specific medical necessity criteria

Covered when ALL of the following general conditions for solid organ transplant are met:

General transplant prerequisites: One evaluation per transplant (a second-opinion evaluation to determine candidacy is approved only at a contracted or in‑network transplant facility when the member was previously turned down); solid organ transplants and related services are covered as defined in coverage documents; all transplant evaluations and transplants must be pre-authorized by Priority Health and performed at a Priority Health approved facility; referrals are directed to Priority Health network or contracted transplant centers.

Behavioral, substance-use and adherence expectations: Patients with a history of substance misuse (including alcohol, tobacco, and other substances) must be abstinent prior to Priority Health approval; the length of abstinence is determined by the transplant center. Drug testing may be required at the discretion of Priority Health. Use of medical marijuana requires treating physician documentation and transplant eligibility is subject to the transplanting institution's criteria. Patients must be willing and able to adhere to post‑transplant lifestyle restrictions and the medical regimen.

Organ-specific: Cornea: Corneal transplants for corneal dystrophies and corneal opacities are eligible; prior authorization is not required for corneal transplants.

Organ-specific: Kidney/Heart/Lung/Pancreas: Kidney, heart, heart‑lung, lung, and pancreas transplants (including SPK/PAK/PTA as applicable) are covered when the transplanting institution's selection criteria are met.

Organ-specific: Liver: Covered for adolescents and adults when transplant center selection criteria are met AND (i) MELD > 15 for patients >12 years or designated Status 1A/1B per OPTN policies, OR (ii) approval by UNOS Regional Review; covered for children <12 when selection criteria are met.MELD > 15 for patients >12 years

Organ-specific: Intestinal/Multivisceral: All of the following must be met: irreversible intestinal failure with failed TPN (examples: impending/overt TPN‑induced liver failure, major central venous thrombosis, frequent line infections/sepsis, frequent severe dehydration despite IV fluids); adequate renal and cardiovascular function; absence of untreated infections and uncontrolled psychiatric disorders that interfere with compliance; controlled HIV per defined criteria; and absence of exclusion conditions (sepsis, multi‑organ failure, advanced neurologic disorders, certain GI diseases, malignancy other than non‑melanomatous skin cancer, congestive heart failure with EF <40%).Creatinine clearance >50 ml/min; Ejection fraction ≥40%

Islet cell transplantation

Islet cell transplantation coverage specifics:

Autologous islet cell transplantation: Covered for patients undergoing near‑total or total pancreatectomy for severe refractory chronic pancreatitis (autologous transplantation of the member's own islet cells).

Limitations on autologous islet transplantation: Autologous islet cell transplantation is not a covered benefit for any indication other than near‑total/total pancreatectomy for severe refractory chronic pancreatitis.

Allogenic islet cell transplantation (transplantation of islet cells from a donor) is not a covered benefit (excluded).

Islet xenografts and retransplantation: Islet cell xenografts are not covered; retransplantation for islet cell transplantation is not covered.

Islet Allotransplant

Pancreas / Islet transplant coverage notes

Islet allotransplant investigational status: Implantation of deceased donor islets of Langerhans is a promising treatment for type 1 diabetes with labile diabetes and recurrent hypoglycemia, but in the United States islet cell allotransplant is currently investigational and subject to FDA tissue and biologic/drug provisions; investigational status may affect coverage decisions.

Intestinal Transplant

Intestinal transplant coverage context

Indications for intestinal transplantation: Intestinal transplantation is an established therapy for permanent intestinal failure when patients cannot be safely maintained on TPN or have life‑threatening PN‑related complications; many adults with benign chronic IF who remain PN‑dependent beyond roughly 2 years and develop PN‑related complications may be candidates. Early intestinal transplantation has improved outcomes but is not yet standard of care.

General medical necessity and investigational review

Coverage and medical necessity review

Medical necessity review and prior authorization: Prior authorization may be required for certain drugs, devices, services and procedures; when prior authorization is required, providers must submit documentation demonstrating medical necessity. Individual case review may allow coverage for investigational yet promising treatments with prior plan approval; determinations for experimental, investigational, or unproven treatments will be made by a Priority Health medical director or clinical pharmacist, with exceptions considered for terminal or severely deteriorating disease.

The policy explicitly considers xenotransplantation and several specific liver transplant techniques to be experimental and not covered. Examples called out include heterotopic (auxiliary) liver transplantation, hepatocellular transplantation, and bioartificial liver transplantation, and xenotransplantation of any organ is stated as not a covered benefit. Providers should not expect coverage for these approaches absent a separate, documented exception or trial arrangement.

Allogenic islet cell transplantation (implantation of deceased donor islets) is explicitly not covered by the policy and is treated as an excluded/investigational therapy. In contrast, autologous islet transplantation performed at the time of pancreatectomy for refractory chronic pancreatitis is recognized in the document as a distinct entity; however, retransplantation for islet cell transplantation is not covered. Providers should request prior authorization only for covered autologous procedures and recognize that allogeneic islet procedures are excluded.

For Priority Health Medicare members, CPT 48160 (pancreatectomy with autologous transplantation of pancreas or pancreatic islet cells) is specifically listed as not covered. This Medicare-specific noncoverage applies to that code as documented in the coding section and should be applied when submitting claims for Medicare products.

The policy designates a set of procedure and laboratory codes as Not Medically Necessary and therefore excluded from coverage. Examples listed include CPT codes 0494T–0496T (ex vivo lung perfusion procedures), 0894T–0896T (liver normothermic machine perfusion procedures), HCPCS/PLA codes such as S2102 (allogeneic islet cell transplant), and other codes including S9975, 81560, 0542U, and 0581U. Claims for services billed with these codes are subject to denial under the Not Medically Necessary designation.

The policy records a material change removing a prior fixed abstinence timeframe: the previous requirement that patients with a history of substance abuse demonstrate 3 months of abstinence before transplant approval has been deleted. Current expectations regarding abstinence and testing are to be determined by the transplant center and documented in the authorization request rather than enforced as a single, plan-wide 3‑month threshold.

The document clarifies that islet cell allotransplantation (allogeneic) is considered investigational in the United States and is not a covered benefit under the policy. This investigational designation means such procedures are routinely treated as not covered/not medically necessary and are subject to applicable FDA tissue and biologic/drug regulations.

Because islet cell allotransplant is described as investigational in the United States, the policy states it may be treated as not medically necessary or excluded under investigational treatment rules. Centers performing islet transplantation are expected to follow FDA registration and tissue-practice guidance, but the investigational status precludes routine coverage.

The policy explicitly designates a specific set of CPT/HCPCS/PLA codes as Not Medically Necessary; these codes are listed in the coding section and include, but are not limited to, 0494T–0496T, 0894T–0896T, S2102, S2103, S2152, S9975, 81560, 0542U, and 0581U. Services billed with these codes are excluded from coverage under the Not Medically Necessary classification.

Candidate Selection and Behavioral Requirements

Behavioral and substance-use candidate criteria

Candidate behavioral and substance-use related expectations:

Abstinence requirement: Patients with a history of substance misuse (including alcohol, tobacco, and other substances) must be abstinent prior to Priority Health approval; the required length of abstinence is determined by the transplant center.

Tobacco testing and contraindication: Tobacco use is listed as a contraindication to transplant surgery; urine testing for cotinine, anabasine, and nornicotine is recommended to document tobacco status. Laboratory thresholds vary by lab; urinary cotinine may range 10–50 ng/mL, anabasine >10 ng/mL or nornicotine >30 ng/mL indicate current tobacco use. Local laboratory cutoffs should be used to determine positivity.urinary cotinine ~10–50 ng/mL; anabasine >10 ng/mL; nornicotine >30 ng/mL

Intestinal transplant candidate physiologic criteria

Candidate physiologic criteria for intestinal/multivisceral transplant:

Procedure and Billing Codes

Corneal transplant codesCPTCovered

65710	Keratoplasty (corneal transplant); anterior lamellar
65730	Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
65750	Keratoplasty (corneal transplant); penetrating (in aphakia)
65755	Keratoplasty (corneal transplant); penetrating (in pseudophakia)
65756	Keratoplasty (corneal transplant); endothelial
65757	Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)
V2785	Processing, preserving and transporting corneal tissue (Corneal tissue reimbursement for ASC, OP Hosp)
65780	Ocular surface reconstruction; amniotic membrane transplantation , multiple layers
65781	Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor)
65782	Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft)

Not separately payable / Unlisted corneal proceduresCPTNot Covered

66999

Unlisted procedure, anterior segment of eye. If billed for corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar keratoplasty (explanatory notes must accompany claim for unlisted procedures)

Kidney transplant codesCPTCovered

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
50325	Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation
50328	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
50340	Recipient nephrectomy (separate procedure)
50370	Renal allotransplantation, implantation of graft; without recipient nephrectomy
50380	Renal allotransplantation, implantation of graft; with recipient nephrectomy; Removal of transplanted renal allograft; Renal autotransplantation, reimplantation of kidney

Heart transplant codesCPTCovered

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

Heart-lung transplant codesCPTCovered

33930	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

Liver transplant codesCPTCovered

47133	Donor hepatectomy (including cold preservation), from cadaver donor
47135	Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
47140	Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)
47141	Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)
47142	Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)
47143	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation
47144	Backbench standard preparation of cadaver donor whole liver graft; with trisegment split into 2 partial grafts
47145	Backbench standard preparation of cadaver donor whole liver graft; with lobe split into 2 partial grafts
47146	Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each
47147	Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each

Lung transplant codesCPT / HCPCSCovered

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver
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 lung allograft prior to transplantation; unilateral
32856	Backbench standard preparation of cadaver donor lung allograft prior to transplantation; bilateral
S2060	Lobar lung transplantation
S2061	Donor lobectomy (lung) for transplantation, living donor

Pancreas and islet transplant codesCPT / HCPCSCovered

48160	Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells (Not covered for Priority Health Medicare)
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
S2065	Simultaneous pancreas kidney transplantation

Lung transplant CPT/HCPCSCPTCovered

32850	Donor pneumonectomy(s) (including cold preservation), from cadaver.
32851	Donor 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 lung allograft prior to transplantation; unilateral.
32856	Backbench standard preparation of cadaver donor lung allograft prior to transplantation; bilateral.
S2060	Lobar lung transplantation
S2061	Donor lobectomy (lung) for transplantation, living donor

Pancreas transplant CPT/HCPCSCPTCovered

48160	Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells (Not covered for Priority Health Medicare)
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
S2065	Simultaneous pancreas kidney transplantation

Islet cell transplant CPT/HCPCSHCPCSCovered

G0341	Percutaneous islet cell transplant, includes portal vein catheterization and infusion.
G0343	Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion.

Intestinal / multivisceral transplant CPT/HCPCSCPTCovered

44132	Donor enterectomy (including cold preservation), open; from cadaver.
44133	Donor enterectomy (including cold preservation), open; partial, from living donor.
44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; from living donor.
44137	Removal of transplanted intestinal allograft, complete
44715	Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation
44720	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
44721	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
S2053	Transplantation of small intestine, and liver allografts
S2054	Transplantation of multivisceral organs

1–10 of 11

1/2

Lab drug testing codesCPT|HCPCSCovered

80307	Drug test(s), presumptive, any number of drug classes, per date of service
80323	Drug test(s), presumptive, by instrument chemistry analyzers or mass spectrometry, per date of service
G0480	Drug test(s), definitive, utilizing GC/MS or LC/MS methods, includes specimen validity testing

Codes designated Not Medically NecessaryCPT|HCPCS|PLANot Covered

0494T	Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system
0495T	Initiation and monitoring marginal cadaver donor lung organ perfusion system; first two hours
0496T	Initiation and monitoring marginal cadaver donor lung organ perfusion system; each additional hour
0894T	Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation
0895T	Connection of liver allograft to normothermic machine perfusion device; initial 4 hours monitoring
0896T	Connection of liver allograft to normothermic machine perfusion device; each additional hour
S2102	Islet cell tissue transplant from pancreas; allogeneic
S2103	S2103 (listed as Not Medically Necessary)
S2152	Adrenal tissue transplant to brain (listed as Not Medically Necessary)
S9975	Transplant related lodging, meals and transportation, per diem (listed as Not Medically Necessary)

1–10 of 13

1/2

MELD score

MELD score thresholdMELD > 15 for adolescents and adults (patients > 12 years)

PurposeUsed to prioritize adult liver transplant candidates per policy and OPTN criteria

Age noteMELD score referenced specifically for patients older than 12 years

Creatinine clearance (Intestinal transplant)

Authorization, Documentation, and Billing Actions

Prior Authorization

Prior authorization required for all transplant evaluations and procedures

All transplant evaluations and transplant procedures must be pre-authorized by Priority Health and be performed at a Priority Health–approved facility; authorization requests should be submitted on the Solid Organ Transplant prior authorization form.

One evaluation per transplant; second-opinion evaluations are approved only at a contracted/in‑network transplant facility when a member was previously turned down.
Referrals should be directed to Priority Health network or contracted transplant facilities per the Provider Manual.

Prior Authorization

Request authorization for listed transplant procedure codes

Providers should request prior authorization for the transplant and related procedure codes listed in the policy when submitting an authorization request.

Include the applicable CPT/HCPCS codes from the policy (e.g., corneal, kidney, heart, heart‑lung, liver, lung, pancreas/islet, intestinal code groups) on the authorization request and claims.

Pre-Transplant Evaluation and Center Requirements

Prior Authorization

One evaluation per transplant; second opinions only at contracted in‑network centers

One transplant evaluation is allowed per transplant; if a second‑opinion evaluation is requested after a prior denial, it will be approved only at a contracted/in‑network transplant facility.

Prior Authorization

Second‑opinion evaluations limited to contracted in‑network facilities

Repeat: only one evaluation per transplant is permitted; second‑opinion evaluations after a prior denial are approved at contracted/in‑network transplant facilities.

Note

Appendix and guideline references include tobacco indicators and professional society guidance

Appendix material and referenced guidance include indicators for tobacco use and cite professional society guidance (AASLD, AST, European Society) to inform candidate evaluation and documentation practices.

Contraindications and Exclusions

Tobacco use is identified as a contraindication to transplant surgery and is included among conditions that may preclude candidacy. Other contraindications noted in the policy include active sepsis, multi‑organ failure, and advanced neurological disorders. These conditions should be documented in the candidate evaluation and will influence eligibility and authorization decisions.

The policy reiterates that tobacco use is a contraindication for transplant and that other exclusionary conditions—such as active sepsis, multi‑organ failure, advanced neurologic disease, and uncontrolled psychiatric conditions that impair adherence—are considered when determining transplant eligibility. Documentation of tobacco cessation testing and treatment plans may be requested as part of prior authorization.

The excerpted document segment does not present an exhaustive list of absolute or relative contraindications; it notes that some contraindications are described elsewhere and that final determinations rely on transplant center selection criteria and referenced national guidance. Providers should consult the full policy and cited NCD/guideline references for comprehensive contraindication guidance.

Consistent with other sections, the policy lists tobacco use and clinical states such as active sepsis, multi‑organ failure, and advanced neurologic disease among conditions that contraindicate transplant. These items inform candidate evaluation and are considered alongside organ‑specific exclusion criteria when assessing medical necessity.

Post-Transplant Follow-up and Coverage Limits

Post-transplant follow-up care

Post-transplant follow-up duration (facility)Follow-up care and services covered at the transplant facility for one year post-transplant for both contracted and non-contracted facilities

Applies toCovers both contracted and non-contracted transplant facilities for initial 1-year period

IncludesClinical follow-up services provided by the transplant facility during the first year after transplant

Long-term post-transplant care

Long-term follow-up beyond 1 yearBeyond one year, follow-up is covered at contracted transplant facilities; at non-contracted facilities only physician services are covered and testing/labs/imaging are in-network only

Facility type distinction

Key Definitions and Testing Thresholds

Tobacco cessation testing

Urine testing panel for tobacco verificationUrine testing for cotinine, anabasine, and nornicotine is recommended to distinguish active tobacco use from passive exposure or nicotine replacement

Analytical rationaleAnabasine and nornicotine help distinguish tobacco use from nicotine replacement; cotinine has longer half-life and is commonly used

Testing logisticsUrine testing preferred over serum/plasma; lab cutoffs vary and laboratory thresholds should be applied

MELD score (definition)

DefinitionModel for End-stage Liver Disease (MELD) score used to prioritize liver transplant candidates

Policy applicationPolicy references MELD > 15 as a coverage criterion for adolescents and adults (>12 years)

Key Metrics, Outcomes, and Highlights

1 yearpost-transplant follow-up covered at transplant facility

MELD > 15liver transplant MELD threshold for adults (>12 years)

30 daysdonor medical expenses covered post-discharge for uninsured donors

Not coveredxenotransplantation (all organs) status

Background and References

Solid organ transplantation is recognized in this policy as an established therapy for end‑stage organ failure, with coverage contingent on meeting general and organ‑specific selection criteria and prior authorization at a Priority Health approved facility. The policy emphasizes that selection criteria vary by organ and transplanting center, and that behavioral factors (including substance use and adherence) and clinical thresholds (for example MELD > 15 for adult liver candidates) are used to determine medical necessity. Providers should furnish transplant center selection documentation and prior authorization requests consistent with the stated criteria.

The background section for intestinal transplantation has been updated with revised text and references. It emphasizes that intestinal transplantation is indicated for permanent intestinal failure when parenteral nutrition fails or leads to life‑threatening complications, and it cites outcomes and guideline literature to inform candidate selection. Providers should refer to the cited CMS NCDs and specialty society publications included in the updated background for detailed guidance on indications and timing.

Policy Changes and Revision History

as of document updatematerial_removalLatest

Removed the 3-month abstinence/length-of-time requirement for patients with a history of substance abuse as a precondition for transplant approval (deletion of section 1.A.5).

as of document updatebackground_and_references_updated

Updated background text and reference list for the intestinal transplant section (clarification/non-material update).

Policy Summary

Payerpriority health

PolicyTRANSPLANTATION OF SOLID ORGANS

Policy CodePolicy 91272

Change TypeMaterial deletion and clarifications

Effective DateJun 1, 2026

Next Review DateMay 1, 2026

Key ActionSubmit prior authorization using the Solid Organ Transplant prior authorization form and ensure transplant and evaluations occur at a Priority Health approved facility.

SourceLink

On This Page

Intestinal transplant physiologic prerequisites: Irreversible intestinal failure when the patient cannot be safely maintained on TPN (examples of failed TPN include impending/overt TPN‑induced liver failure, major central venous thrombosis, frequent line infection/sepsis, frequent severe dehydration despite IV fluids); and all of the following must be present: adequate kidney function and cardiovascular function, absence of uncontrolled infections and untreated psychiatric disorders interfering with compliance, and controlled HIV per defined criteria.Creatinine clearance >50 ml/min; Ejection fraction ≥40%

Intestinal transplant candidates

Candidates for intestinal transplantation

Permanent IF candidacy: Patients with permanent intestinal failure who cannot meet nutritional needs enterally and who have PN failure or life‑threatening PN‑related complications may be candidates for intestinal transplantation. Many adult patients with benign chronic IF who remain PN‑dependent beyond approximately 2 years with complications are considered for transplant; pediatric timelines may differ due to prolonged adaptation.Typically after ~2 years of TPN with complications

Candidate evaluation references

Clinical and guideline references relevant to candidate evaluation and indications (document cites NCDs and specialty society guidance).

Referenced guidance: CMS National Coverage Determinations and specialty society guidelines (e.g., AASLD, AST, American Society of Transplantation) are cited for liver, heart, intestinal, pancreas/islet cell transplants and inform candidate evaluation and indications; these references should be consulted when determining candidacy and program requirements.

Intestinal transplant candidate references

References and position papers relevant to candidate selection for intestinal transplantation are cited.

Key intestinal transplant references: Position papers and systematic reviews (for example ASOT pediatric position paper and recent systematic reviews and registry analyses) are cited to guide candidate selection, induction regimens, and outcomes reporting; see cited literature for clinical detail.

Creatinine clearance requirementCreatinine clearance greater than 50 ml/min

ContextRequired physiologic criterion for intestinal/multivisceral transplant candidacy

Related conditionsPart of combined organ-function prerequisites including cardiac EF and absence of uncontrolled infections

Ejection fraction (Intestinal transplant)

Ejection fraction requirementEjection fraction greater than or equal to 40%

ContextRequired cardiovascular function parameter for intestinal/multivisceral transplant candidacy

Contraindication thresholdCongestive heart failure with EF < 40% is listed as exclusion for intestinal transplant

Urinary anabasine (tobacco testing)

Urinary anabasine thresholdAnabasine > 10 ng/mL in urine indicates current tobacco use

SpecificityAnabasine is present in tobacco products but not in nicotine replacement therapies

Laboratory variabilityReference ranges may vary by laboratory; use the lab's threshold to determine positivity

Urinary nornicotine (tobacco testing)

Urinary nornicotine thresholdNornicotine > 30 ng/mL in urine indicates current tobacco use

InterpretationPresence of nornicotine without anabasine is consistent with nicotine replacement product use

Laboratory variabilityReference ranges may vary by laboratory; use the lab's threshold to determine positivity

Time on parenteral nutrition (Permanent IF)

Typical PN duration before considering permanent IFPermanent intestinal failure often considered after approximately 2 years of total parenteral nutrition (TPN) with complications or failure

RationaleHigh rates of PN-related complications and low likelihood of further enteral adaptation after 2 years support consideration of transplant

Adult vs pediatricAdult patients more likely to have permanent IF after 2 years; pediatric patients may adapt over a longer period

Drug testing limits (Tobacco verification labs)

Prior auth for tobacco verification labsNo prior authorization required for tobacco cessation verification lab tests

Coding/limitsTesting is subject to drug testing limits per policy 91611

Covered lab CPT/HCPCSExamples of covered testing codes include 80307, 80323, G0480 when performed per policy description

Step Therapy

Step therapy: not specified

No step therapy rules are specified in this policy section; treatment sequencing requirements are not defined here.

Not applicable/not specified in this section for step therapy.

Note

Prior authorization influenced by UNOS/OPTN, CMS and internal policy updates

Prior authorization requirements and review may be influenced by UNOS/OPTN and CMS National Coverage Determinations and by Priority Health internal policy updates.

The policy removes the prior fixed 3‑month abstinence requirement for substance abuse (see deletions) but prior authorization decisions remain informed by national and internal policy guidance.

Prior Authorization

Pre-authorization and facility requirement

Transplants and transplant evaluations must be pre‑authorized and performed at Priority Health approved facilities; submit the Solid Organ Transplant prior authorization form to initiate authorization.

Second‑opinion evaluations to determine candidacy are only approved at contracted/in‑network transplant facilities when the member was previously turned down.

Denial Risk

Re‑transplantation denial risk if patient non‑compliance contributed to failure

Priority Health may deny re‑transplantation when, in the Plan’s opinion, patient non‑compliance with treatment recommendations significantly contributed to the transplant failure.

Document adherence history and clinical justification when requesting authorization for re‑transplantation.

Denial Risk

Investigational status: islet allotransplant

Islet cell allotransplantation (allogeneic implantation of donor islets) is considered investigational in the United States and is subject to FDA tissue and biologic/drug provisions; investigational status may result in noncoverage or denial.

Centers performing islet procedures should be registered with the FDA and follow Current Good Tissue Practices.

Denial Risk

Denial risk for services coded as Not Medically Necessary

Claims including procedures designated Not Medically Necessary in the policy risk denial or exclusion from coverage.

Examples of NMN codes include CPT 0494T–0496T, 0894T–0896T, S2102, S2103, S2152, S9975, 81560, 0542U, and 0581U; verify coding against the policy before submission.

Denial Risk

Risk if behavioral/substance‑use requirements are not met after policy update

Removal of the specific 3‑month abstinence time requirement does not eliminate behavioral/substance‑use evaluation expectations; failure to meet the transplant center’s abstinence or behavioral requirements may still risk prior authorization denial.

The length of abstinence is determined by the transplant center; Priority Health may require drug testing at its discretion.

Documentation Required

Document tobacco/substance testing and thresholds

Use tobacco cessation testing results and laboratory thresholds to document tobacco use status when relevant to transplant candidacy; local laboratory cutoffs should be applied.

Urinary cotinine thresholds may vary (approximately 10–50 ng/mL); anabasine >10 ng/mL or nornicotine >30 ng/mL in urine indicate current tobacco use.
Urine testing is recommended over serum/plasma testing and reference ranges vary by laboratory.

Documentation Required

Transplant evaluation, donor and follow‑up documentation requirements

Provide documentation of transplant center selection, evaluation findings and donor information when requested; if a second‑opinion evaluation is requested after a prior denial, submit documentation from the contracted transplant facility.

Donor expense eligibility: for donors without other insurance, Priority Health covers medical expenses related to donation for 30 days post‑discharge; document donor insurance status.
Follow‑up care is covered at the transplant facility for one year post‑transplant; beyond one year coverage differs for contracted vs non‑contracted facilities.

Billing Rule

Submit applicable transplant procedure codes and supporting documentation

When requesting authorization or submitting claims, include the applicable CPT/HCPCS procedure codes listed in the policy for the specific transplant procedure and supporting clinical documentation to demonstrate medical necessity.

Codes are grouped by organ type in the policy coding section; include donor, backbench preparation and removal codes when applicable.

Documentation Required

Prior authorization documentation must demonstrate medical necessity and may reference external criteria

When prior authorization is required, submit requests that demonstrate medical necessity and reference external guideline criteria (EviCore, InterQual, TurningPoint) via Priority Health Prism as needed; individual case review may be requested for investigational yet promising therapies.

All determinations for experimental or investigational treatments are made by a Priority Health medical director or clinical pharmacist; requests for exceptions require prior plan approval.

Documentation Required

Reference UNOS/OPTN and CMS NCDs in authorization and program documentation

Reference UNOS/OPTN policies and CMS National Coverage Determinations as program‑level guidance when preparing authorization requests and program documentation.

UNOS/OPTN policies and CMS NCDs cited in the policy inform candidate evaluation and center requirements; include relevant citations in complex or programmatic requests.

Prior Authorization

Prior authorization submissions must demonstrate medical necessity and may reference EviCore/InterQual/TurningPoint

Submit prior authorization requests that demonstrate medical necessity; external guideline criteria (EviCore, InterQual, or TurningPoint) may be used via Priority Health Prism to support the request.

Prior Authorization

Evaluation limit: one per transplant; second opinions only at contracted centers

One evaluation per transplant is permitted; second‑opinion evaluations are approved only at contracted/in‑network transplant facilities when previously turned down.

Note

All evaluations and transplants must occur at Priority Health–approved facilities

All transplant evaluations and transplants must be performed at a Priority Health approved facility and referrals directed to Priority Health network or contracted transplant centers.

Contracted centers: continued comprehensive follow-up; Non-contracted centers: limited to physician services with ancillary services in-network only

Implication for patientsPatients requiring ongoing testing, labs, or imaging after year one should access contracted transplant centers for coverage of those services

Follow-up and long-term outcomes reporting

Outcomes and survival metrics referencedPolicy references graft and patient survival statistics at 1, 5, and 10 years (graft survival 71%/50%/40%; patient survival 77%/58%/47%)

PurposeOutcomes and survival statistics used to inform expectations and long-term reporting; explicit post-transplant coverage durations beyond one year are not specified here

ReferencesRegistry and literature citations in the intestinal transplant section support these reported outcomes

Removal of transplanted organ / Backbench preparation

Removal and backbench codes includedCodes for removal of transplanted allografts and backbench preparation/reconstruction are listed and considered part of the transplant procedure bundle when applicable

ExamplesIncluded CPT codes cover backbench preparation and reconstruction for liver, kidney, pancreas, and intestine allografts as listed in coding sections

Billing implicationWhen applicable, these services are bundled with transplant procedures per policy coding guidance

Intestine transplant follow-up and immunosuppression management

Refer to cited literature for regimens and risksPolicy references induction regimens, post-transplant risks (e.g., post-transplant lymphoproliferative disorder), and outcome studies for intestine transplant immunosuppression management

Clinical sourcesCited pediatric single-center experience and systematic reviews provide guidance on induction regimens and long-term management

Coverage notePolicy points readers to cited literature rather than specifying a single immunosuppression regimen in the coverage document

Guideline sourcesPolicy cites CMS NCD and transplant society literature regarding MELD use and updates

Islet allotransplant (definition)

DefinitionIslet allotransplant: implantation of deceased donor islets of Langerhans as treatment for type 1 diabetes with labile diabetes and recurrent hypoglycaemia

Regulatory statusIn the United States, islet cell allotransplant is currently investigational and subject to FDA tissue and biologic/drug provisions

Clinical contextCenters performing islet transplants should be registered with the FDA and follow Current Good Tissue Practices

Permanent intestinal failure (IF)

DefinitionPermanent intestinal failure (IF): anatomic or functional reduction of intestinal mass resulting in inability to meet nutritional needs without intervention

Clinical consequenceLeads to severe dehydration and malnutrition; may require lifelong parenteral nutrition or intestinal transplantation

Natural historyAbout 50% of adult patients with benign chronic IF achieve enteral autonomy within first 2 years; after that many remain PN-dependent

NCD (National Coverage Determination)

DefinitionNational Coverage Determination (NCD) by CMS referenced for specific organ transplants (e.g., adult liver, heart, intestinal transplants)

Policy impactPolicy references NCDs to inform medical necessity and program-level requirements for transplants

ExamplesSpecific NCDs cited include adult liver transplantation, heart transplants, intestinal and multivisceral transplantation, and islet cell transplantation in trial contexts

Intestinal transplant (definition)

DefinitionIntestinal transplant: surgical replacement of part or all of the small intestine for indications such as short bowel syndrome and permanent intestinal failure

IndicationsConsidered when PN fails or PN-related complications are life-threatening; often after ~2 years of TPN in adults

OutcomesRegistry data cited for graft and patient survival at 1, 5, and 10 years