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Modifiedpriority healthPolicy 91272

Transplantation of Solid Organs

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Defines Priority Health coverage, medical necessity criteria, limitations, and administrative requirements for evaluation, transplant procedures, donor services, and post‑transplant care for solid organ transplants.

Policy Summary

Payerpriority health

PolicyTransplantation of Solid Organs

Policy CodePolicy 91272

Change TypeRemoved substance-abuse 3‑month abstinence requirementbackground updates

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization on the Solid Organ Transplant prior authorization form for all transplant evaluations and transplants (except corneal), and ensure procedures 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

MELD >15MELD threshold

cornea exceptioncorneal exception

xenotransplantationnot covered (examples)

codes listedcodes included

Coverage Criteria for Solid Organ Transplantation

General and organ‑specific covered criteria

Covered when ALL of the following common conditions are met (applies to all solid organ transplants except where noted):

General authorization and facility requirements: One evaluation per transplant; transplant evaluations and transplants must be pre-authorized by Priority Health and performed at a Priority Health approved facility; referrals directed to Priority Health network or contracted facilities.

Second opinion/second evaluation may be approved at a contracted/in-network transplant facility if the member was previously turned down for transplant.

Substance use and compliance: Patients with a history of substance misuse (including alcohol, tobacco, and other substances) must be abstinent prior to approval; drug testing may be required; medical marijuana requires treating physician documentation; patients must be willing and able to adhere to post-transplant lifestyle restrictions and medical regimen.

Length of abstinence is at the discretion of the transplant center.

Donor expense limits:

Policy Summary

Payerpriority health

PolicyTransplantation of Solid Organs

Policy CodePolicy 91272

Change TypeRemoved substance-abuse 3‑month abstinence requirementbackground updates

Effective DateJun 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

Expenses incurred after organ harvesting and hospital discharge are not covered for donors who have other active insurance; for donors without other insurance, medical expenses directly related to donation are covered for 30 days post-discharge.

Transportation and lodging are not covered unless specified in coverage documents.

Liver transplant specific: For adolescents and adults, coverage requires the transplanting institution's selection criteria AND either a MELD score greater than 15 (patients >12 years) OR UNOS regional review approval.MELD > 15

Children under 12 years: covered when center selection criteria are met.

Islet cell transplantation

Islet cell transplantation coverage rules:

Autologous islet cell transplantation: Covered only as autologous islet cell transplantation for patients undergoing near-total or total pancreatectomy for severe refractory chronic pancreatitis.

Allogenic islet cell transplantation, islet cell xenografts, and islet cell retransplantation are not covered.

Intestinal/multivisceral transplant

Intestinal/multivisceral transplant coverage requirements (ALL must be met):

Primary indication: Irreversible intestinal failure when the patient can no longer be safely maintained on total parenteral nutrition (TPN); examples include impending or overt TPN-induced liver failure, thrombosis of major central venous channels, frequent line infections/sepsis, or frequent severe dehydration despite IV fluids and TPN.

Pre-transplant organ/function and infection criteria: Adequate kidney function defined as creatinine clearance > 50 ml/min; adequate cardiovascular function defined as ejection fraction >= 40%; absence of acute or chronic untreated infections; no uncontrolled or untreated psychiatric disorders that interfere with compliance; absence of inadequately controlled HIV/AIDS (CD4 > 200 cells/mm3 for >6 months, undetectable viral load, on stable ART >3 months, no AIDS complications).CrCl > 50 ml/min; EF >= 40%; CD4 > 200

Exclusion list: Contraindications include sepsis, multi-organ failure, advanced neurological disorders (for example neuroaxonal dystrophy, Tay-Sachs, Niemann-Pick and variants, neuronal ceroid lipofuscinosis, Huntington disease), presence of other gastrointestinal diseases (e.g., bleeding peptic ulcer, diverticulitis, chronic hepatitis), malignancy other than non-melanomatous skin cancer, and congestive heart failure with refractory symptoms and EF < 40%.EF >= 40%

Pancreas / Islet Cell Transplant Criteria

Pancreas and islet transplants

Islet allotransplant status: Islet cell allotransplantation in the United States is considered investigational and subject to FDA tissue rules and biologic/drug provisions; centers performing islet cell transplants should be registered with the FDA and follow Current Good Tissue Practices.

Document regulatory/investigational status and FDA requirements when considering islet allotransplantation.

Intestinal Transplant Criteria

Intestinal transplant

Indications for intestinal transplant: Permanent intestinal failure (IF) with inability to meet nutritional requirements and dependence on parenteral nutrition (PN) where PN-related complications or PN failure occur; consider documentation of PN dependence, duration, complications, and attempts at enteral adaptation.

Early transplantation may be considered in select cases but is not standard of care; outcomes and survival metrics should inform decision-making.

Not Medically Necessary Procedures and Codes

The following procedure codes are designated Not Medically Necessary when used as described:

Not Medically Necessary Procedures: The policy lists the following codes as Not Medically Necessary when used as described: 0494T, 0495T, 0496T, 0894T, 0895T, 0896T, S2102, S2103, S2152, S9975, 81560, 0542U, and 0581U.

These codes are explicitly included in the policy's Not Medically Necessary section.

Xenotransplantation and several specific experimental liver procedures are not covered. Xenotransplantation of any organ is explicitly designated as not covered, and the policy lists the following liver-related procedures as investigational and not covered: heterotopic/auxiliary (ectopic) liver transplantation, hepatocellular transplantation, and bioartificial liver transplantation.

Allogenic islet cell transplantation and islet cell xenografts are explicitly listed as not covered. The policy permits autologous islet cell transplantation only for patients undergoing near-total or total pancreatectomy for severe refractory chronic pancreatitis; all other indications for autologous transplantation are not covered. Retransplantation of islet cells is also stated as not covered.

The procedure 48160 (pancreatectomy with autologous transplantation of pancreas or pancreatic islet cells) is specifically designated as not covered for Priority Health Medicare members.

CPT codes 0494T and 0495T, which describe the surgical preparation/cannulation and the initiation/monitoring of marginal donor lung ex vivo perfusion systems, are listed in the policy as Not Medically Necessary when performed as described.

Certain services and procedure codes are listed as Not Medically Necessary in the policy. Examples include S2102, S2103, S2152, and selected PLA/algorithm codes (for example, 81560, 0542U, 0581U). These items are included in the not medically necessary section and should not be billed as covered services.

Priority Health may deny retransplantation when, in the Plan's opinion, patient non-compliance with treatment recommendations was a significant contributor to the initial transplant failure. This applies to retransplantation requests and is an explicit exclusion from coverage in such circumstances.

For emphasis, CPT codes 0494T and 0495T are explicitly listed in the policy's Not Medically Necessary section for marginal donor lung ex vivo perfusion procedures; related perfusion and monitoring codes (e.g., 0496T, 0894T, 0895T, 0896T) are also identified as not medically necessary.

The policy identifies multiple perfusion and monitoring CPT codes and several transplant-related procedure and algorithm codes in its not medically necessary list. Perfusion/monitoring codes include 0494T, 0495T, 0496T, 0894T, 0895T, 0896T. The policy also lists transplant-specific HCPCS/PLA/algorithm codes such as S2102, S2103, S2152, S9975, 81560, 0542U, 0581U as not medically necessary or included in the same section.

Procedure and Billing Codes

Corneal Transplant CodesCPTCovered

65710	Keratoplasty (corneal transplant); anterior lamellar.
65730	Keratoplasty; penetrating (except in aphakia or pseudophakia).
65750	Keratoplasty; penetrating (in aphakia).
65755	Keratoplasty; penetrating (in pseudophakia).
65756	Keratoplasty; endothelial.
65757	Backbench preparation of corneal endothelial allograft prior to transplantation.
V2785	Processing, preserving and transporting corneal tissue.
65780	Ocular surface reconstruction; amniotic membrane transplantation, multiple layers.
65781	Ocular surface reconstruction; limbal stem cell allograft.
65782	Ocular surface reconstruction; limbal conjunctival autograft.

Unlisted anterior segment codeCPT

66999

Unlisted procedure, anterior segment of eye.

Kidney Transplant CodesCPTCovered

50300	Donor nephrectomy; from cadaver donor.
50320	Donor nephrectomy; open, from living donor.
50323	Backbench standard preparation of cadaver donor renal allograft.
50325	Backbench standard preparation of living donor renal allograft.
50327	Backbench reconstruction of renal allograft; venous anastomosis.
50328	Backbench reconstruction of renal allograft; arterial anastomosis.
50329	Backbench reconstruction of renal allograft; ureteral anastomosis.
50340	Recipient nephrectomy (separate procedure).
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy.
50365	Renal allotransplantation, implantation of graft; with recipient nephrectomy.

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Heart Transplant CodesCPTCovered

33940	Donor cardiectomy (including cold preservation).
33944	Backbench standard preparation of cadaver donor heart allograft.
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.
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.
47140	Donor hepatectomy; living donor; left lateral segment only.
47141	Donor hepatectomy; living donor; total left lobectomy.
47142	Donor hepatectomy; living donor; total right lobectomy.
47143	Backbench standard preparation of cadaver donor whole liver graft; without trisegment or lobe split.
47144	Backbench standard preparation; with trisegment split into 2 partial liver grafts.
47145	Backbench standard preparation; with lobe split into 2 partial liver grafts.
47146	Backbench reconstruction of liver graft; venous anastomosis, each.
47147	Backbench reconstruction of liver graft; arterial anastomosis, each.

Lung Transplant 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; without cardiopulmonary bypass.
32854	Lung transplant, double; with cardiopulmonary bypass.
32855	Backbench standard preparation of cadaver donor lung allograft; unilateral.
32856	Backbench standard preparation of cadaver donor lung allograft; bilateral.
S2060	Lobar lung transplantation.
S2061	Donor lobectomy (lung) for transplantation, living donor.

Pancreas and Islet Cell Transplant Codesmixed

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).
48551	Backbench standard preparation of cadaver donor pancreas allograft.
48552	Backbench reconstruction of cadaver donor pancreas allograft; venous anastomosis, each.
48554	Transplantation of pancreatic allograft.
48556	Removal of transplanted pancreatic allograft.
S2065	Simultaneous pancreas kidney transplantation.
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.

Intestinal and Multivisceral Transplant CodesCPTCovered

44132	Donor enterectomy (including cold preservation), open; from cadaver donor.
44133	Donor enterectomy; 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.
44720	Backbench reconstruction of intestine allograft; venous anastomosis, each.
44721	Backbench reconstruction of intestine allograft; arterial anastomosis, each.
S2053	Transplantation of small intestine, and liver allografts.
S2054	Transplantation of multivisceral organs.

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Drug Testing / Lab CodesCPT|HCPCSCovered

80307	Drug test(s), presumptive, any number of drug classes, by instrument chemistry analyzers.
G0480	Drug test(s), definitive, utilizing GC/MS or LC/MS methods; qualitative or quantitative.

Not Medically Necessary CodesCPTNot Covered

0494T	Surgical preparation and cannulation of marginal donor lung(s) to ex vivo organ perfusion system.
0495T	Initiation and monitoring marginal donor lung(s) organ perfusion system by physician or qualified health care professional.

Laboratory drug testing CPT/HCPCSCPTCovered

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, includes sample validation when performed, per date of service.
G0480	Drug test(s), definitive, utilizing methods able to identify individual drugs (e.g., GC/MS, LC/MS), includes specimen validity testing, per day; 1-7 drug class(es).

Perfusion and monitoring procedure codes (listed as Not Medically Necessary)CPTNot Covered

0494T	Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation.
0495T	Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional.
0496T	Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system; each additional hour.
0894T	Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation following perfusion.
0895T	Connection of liver allograft to normothermic machine perfusion device; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments.
0896T	Connection of liver allograft to normothermic machine perfusion device; each additional hour.

Transplant-specific HCPCS/PLA/algorithm codesmixed

S2102	Islet cell tissue transplant from pancreas; allogeneic.
S2103	Adrenal tissue transplant to brain.
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; procurement, transplantation, and related complications; inclusive global definition.
S9975	Transplant related lodging, meals and transportation, per diem.
81560	Transplantation medicine, measurement of donor and third-party-induced CD154+ T cytotoxic memory cells, algorithm reported as a rejection risk score.
0542U	Nephrology (renal transplant), urine, NMR measurement of 84 urinary metabolites combined with BK virus quantification and serum creatinine, algorithm reported as probability score for allograft injury status.
0581U	Transplantation medicine, antibody to non-HLA, blood specimen, flow cytometry, single-antigen bead technology, 39 targets.

MELD score — liver transplant threshold

MELD score threshold> 15 for patients > 12 years

Applies toAdolescents and adults (>12 years) meeting transplant center selection criteria or UNOS regional review

Children <12 yearsCovered when transplant center selection criteria are met (no MELD threshold)

Anabasine urinary threshold

Anabasine urinary cutoff> 10 ng/mL

InterpretationPresence >10 ng/mL indicates current tobacco use and is not consistent with nicotine replacement therapy

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

Nornicotine urinary threshold

Nornicotine urinary cutoff> 30 ng/mL

InterpretationPresence >30 ng/mL in urine indicates current tobacco use; nornicotine without anabasine may reflect nicotine-replacement product use

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

Probability of permanent intestinal failure after 2 years of TPN (adult)

Probability of permanent IF after 2 years of TPN (adult)Up to 94%

ContextSignificant intestinal adaptation occurs in a minority after 2 years; adults are unlikely to achieve enteral autonomy beyond this period

ImplicationHigh permanent IF probability supports consideration of intestinal transplantation when PN-related complications or failure occur

Normothermic perfusion monitoring — initial time and billing

Initial monitoring time (0895T)Initial 4 hours of monitoring time (code 0895T)

Additional hours (0896T)Each additional hour billed with code 0896T (list separately in addition to primary procedure)

Associated code0894T used for cannulation/decannulation of liver allograft prior to/after normothermic perfusion

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Pre-authorization and approved facility required

All transplant evaluations and transplant procedures (except corneal transplants) require prior authorization and must be performed at a Priority Health–approved transplant facility. Requests for authorization should be submitted on the Solid Organ Transplant prior authorization form and referrals should be directed to Priority Health network or contracted facilities.

Prior Authorization

Prior authorization for listed procedures/tests (cornea exception)

Specific transplant procedure and associated lab/test codes listed in the coding section may require prior authorization or supporting documentation; corneal transplants are explicitly noted as not requiring prior authorization. Lab testing for tobacco-cessation verification is listed as no prior authorization required but is subject to drug testing policy limits.

Corneal transplants: Prior authorization not required (see corneal code list).
Selected procedure and lab codes in the coding section may need prior authorization or documentation per policy and product rules.

Prior Authorization

Use Priority Health Prism for prior authorization criteria

Certain transplant-related drugs, devices, services and procedures may require prior authorization. Use Priority Health Prism -> Authorizations -> Authorization Criteria Lookup to access applicable EviCore, InterQual, or TurningPoint guidelines and submit required documentation when authorization is indicated.

Step Therapy

Liver transplant prerequisites (center criteria + MELD/UNOS)

For liver transplants in adolescents and adults, coverage requires the transplanting institution's selection criteria AND either a MELD score greater than 15 for patients older than 12 years or approval from the UNOS Regional Review; children under 12 are covered when center selection criteria are met.

MELD score > 15 required for patients >12 years when using MELD criteria.

Billing Rule

Tobacco-cessation lab verification codes and limits

Drug testing for tobacco-cessation verification uses the laboratory CPT/HCPCS codes listed (e.g., 80307 and G0480). These tests are noted as not requiring prior authorization for tobacco cessation verification but are subject to the limits and rules in the drug testing policy.

CPT 80307 and HCPCS G0480 are the referenced laboratory codes for drug testing.
No prior authorization required for tobacco cessation verification testing; subject to policy 91611 drug testing limits.

Note

Documentation Required

Document substance use status and medical marijuana

Provider documentation should include the patient's substance-use status and any treating physician documentation supporting medical marijuana use when applicable; Priority Health may require drug testing at its discretion as part of evaluation and authorization.

Document physician support for medical marijuana use when claimed.
Be prepared to submit drug testing results if requested by Priority Health.

Documentation Required

Include procedure-specific transplant codes and supporting documentation

Claims for transplant procedures must include the specific procedure codes listed for each organ type (see coding lists for corneal, kidney, heart, liver, lung, pancreas/islet, intestinal/multivisceral). Include supporting documentation as appropriate for donor/recipient and backbench procedures.

Include donor, backbench, implantation, and removal procedure codes as applicable.
Ensure supporting clinical documentation accompanies codes for authorization and claims.

Documentation Required

Submit medical necessity documentation for prior authorization

When prior authorization is required, providers must submit documentation demonstrating medical necessity and follow product-specific plan rules; consult the Priority Health Provider Manual and Authorization Criteria Lookup for details.

Prior Authorization

Prior authorization and approved facility requirement

Transplant evaluations and transplants must be pre-authorized by Priority Health and performed at a Priority Health approved facility; submit requests on the Solid Organ Transplant prior authorization form and refer members to Priority Health network or contracted facilities.

Denial Risk

Retransplantation denial risk for patient non‑compliance

Priority Health does not cover re-transplantation when, in the Plan's opinion, patient non-compliance with treatment recommendations was a significant contributor to transplant failure; this may lead to denial of re-transplantation requests.

Denial Risk

Denial risk when billing codes listed as Not Medically Necessary

Billing services or procedures that the policy designates as Not Medically Necessary (e.g., listed perfusion/monitoring and select transplant-related codes) may trigger denial if submitted for coverage.

Examples include CPT codes 0494T, 0495T, 0496T, 0894T, 0895T, 0896T and listed HCPCS/PLA/algorithm codes (S2102, S2103, S2152, S9975, 81560, 0542U, 0581U).

Denial Risk

Denial risk for experimental, investigational, or unproven services

Requests for services that are experimental, investigational, or unproven may be denied unless an individual case review by a Priority Health medical director or clinical pharmacist allows coverage; prior authorization may be required for such requests.

Individual case review is required for investigational therapies; exception may be considered for terminal or severely disabling conditions with prior plan approval.

Candidate Evaluation and Selection Criteria

Candidate evaluation and selection

General candidate and organ-specific selection notes:

Evaluation frequency: One transplant evaluation per transplant; a second opinion/second evaluation may be approved at a contracted or in-network transplant facility if the member was previously turned down.

Center selection: Transplants are covered when the transplanting institution's selection criteria are met (explicitly referenced for kidney, heart, heart-lung, lung, pancreas types); liver has additional MELD/UNOS rules.

Substance use for liver candidates: Patients with substance misuse must be abstinent prior to approval; transplant centers determine length of abstinence. AASLD/AST guidance notes length of abstinence should not be an absolute exclusion when disease severity prevents longer sobriety; discontinuing tobacco/smoked marijuana and drug misuse should be expected and monitored.

Intestinal Candidate Criteria

Intestinal transplant candidate considerations

Intestinal transplant candidate: Patient has permanent intestinal failure with PN dependence and either PN-related complications or failure to achieve enteral autonomy after the expected adaptation period; documentation should include duration on PN, PN complications, and likelihood of intestinal adaptation with pediatric timelines differing from adults.

Referenced Candidate Evaluation Guidance

References candidate evaluation guidance and NCDs for specific organs; internal candidate criteria text minimal

Referenced guidance: Policy cites society guidance and CMS National Coverage Determinations (NCDs) for liver, heart, kidney, intestinal, pancreas/islet transplants and other literature to guide candidate evaluation and selection.

Detailed candidate eligibility criteria are referenced but not fully reproduced in this document.

Contraindications to Transplantation

Contraindications include active uncontrolled infections and uncontrolled psychiatric disorders that interfere with adherence to treatment. Active malignancy is excluded from coverage except where specific exceptions are noted in the liver transplant criteria. The policy also documents an operational change removing a prior explicit requirement for a fixed duration of abstinence for substance-abuse history: the prior 3-month abstinence duration requirement was deleted (operational change).

The policy removed a previous explicit requirement that specified a fixed duration of abstinence for patients with a history of substance abuse. Operationally, the prior 3-month abstinence requirement has been deleted and is no longer part of the criteria.

Evaluation and Documentation Requirements

Documentation Required

One evaluation per transplant; testing and documentation may be required

One transplant evaluation is permitted per transplant; evaluations are covered even if active substance abuse is present at the time of evaluation. Drug testing may be required and medical marijuana documentation may be requested.

Second opinion consults for transplant candidacy may be approved at contracted/in‑network transplant facilities if a member was previously turned down.

Documentation Required

Document PN dependence, duration, complications, and adaptation likelihood

For intestinal transplant candidates, document parenteral nutrition (PN) dependence, duration of PN, PN‑related complications, and the likelihood of intestinal adaptation to support transplant consideration.

Document attempts at enteral adaptation and duration on PN; adult and pediatric adaptation timelines differ.

Documentation Required

Submit medical necessity documentation and follow referenced guidance/NCDs

Prior authorization requires submission of medical necessity documentation and adherence to referenced society guidance and applicable NCDs; follow Priority Health Provider Manual and Authorization Criteria Lookup for specific guideline details.

Transplant Center and Program Requirements

Prior Authorization

Center authorization and facility performance requirement

All transplant evaluations and transplants must be pre‑authorized by Priority Health and be performed at a Priority Health approved facility (contracted or in‑network).

Documentation Required

Islet cell transplant centers: FDA registration and CGTP

Centers performing islet cell transplantation should be registered with the FDA and follow Current Good Tissue Practices (CGTP) as described in the policy.

Prior Authorization

Reiteration: pre‑auth and approved facility requirement

Transplant evaluations and transplants must be pre‑authorized by Priority Health and performed at a Priority Health approved facility; referrals should be directed to Priority Health's network or contracted facilities.

Post-Transplant Follow-up and Coverage Limitations

Post-transplant follow-up at transplant facility

Standard post-transplant follow-up duration at transplant facilityFollow-up care and services covered at the transplant facility for one year following transplant

Applies toBoth contracted and non-contracted transplant facilities

ScopeIncludes follow-up care and services as defined in policy

Extended post-transplant care

Follow-up beyond one year (contracted)Covered at contracted transplant facilities beyond one year

Follow-up beyond one year (non-contracted)At non-contracted facilities only physician services are covered; testing, labs, and imaging are covered in-network only

Plan-specific limitsCoverage beyond year one is subject to member's specific benefits and network status

Long-term follow-up (implied)

Long-term follow-up guidanceOutcomes data and graft/patient survival statistics are provided for counseling and expectations; no explicit coverage duration beyond one year is specified

Data providedIntestinal transplant graft and patient survival rates (example: 1-, 5-, 10-year graft survival 71% / 50% / 40%)

ImplicationLong-term surveillance and counseling informed by registry outcomes; coverage governed by plan documents

Post-transplant hospitalization, follow-up, drugs, supplies

Global procedure definitions (example S2152)May include specified days of pre- and post-transplant care, hospitalization, drugs, supplies and outpatient follow-up

Coverage subject to benefitsCoverage of included items is subject to the member's specific benefits and plan documents

Billing noteServices included in a global code may not be separately reimbursable; consult coding section and plan documents

Background and Scope

This policy covers the full scope of solid organ transplantation including cornea, kidney, heart, lung, liver, pancreas, islet cell, intestinal and multivisceral transplants. Corneal transplants are common and, per the policy, do not require prior authorization. The document addresses candidate evaluation, selection, center requirements, contra‑indications, and post‑transplant follow-up.

Definitions and Thresholds

Irreversible intestinal failure — definition

DefinitionIrreversible intestinal failure: inability to be safely maintained on total parenteral nutrition (TPN) due to conditions such as TPN-induced liver failure, central venous thrombosis, frequent line infections/sepsis, or recurrent severe dehydration

Clinical examplesIncludes impending/overt TPN-induced liver injury, major central venous thrombosis, frequent line sepsis, and severe dehydration despite IV fluids

Implication for transplantMeets primary indication for intestinal transplant when present alongside other candidate criteria

Tobacco-use biochemical testing — thresholds

Tobacco-use biochemical testing thresholdsAnabasine > 10 ng/mL or nornicotine > 30 ng/mL in urine indicates current tobacco use

Cotinine rangeUrinary cotinine thresholds may vary (approximately 10-50 ng/mL); use laboratory reference ranges to determine positivity

Testing guidanceUrine testing preferred over serum/plasma; labs' thresholds should be used to interpret results

Permanent Intestinal Failure (IF) — definition

Permanent Intestinal Failure (IF) — definitionAnatomic or functional reduction of intestinal mass resulting in inability to meet nutritional and fluid needs without parenteral nutrition, leading to severe dehydration and malnutrition without intervention

Clinical consequenceWithout intervention, permanent IF leads to severe malnutrition and dehydration; supports consideration for intestinal transplantation

Relation to PNMany adult patients remain PN-dependent long-term; adaptation less likely after two years of TPN

Islet Cell Allotransplant — definition

Islet cell allotransplant — definitionImplantation of deceased-donor islets of Langerhans intended as treatment for type 1 diabetes with labile diabetes, recurrent hypoglycemia and hypoglycemia unawareness

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

Center requirementsCenters performing islet transplants should be registered with the FDA and follow Current Good Tissue Practices

National Coverage Determination (NCD) references

NCD referencesCMS National Coverage Determinations (NCDs) are referenced for specific transplant types (e.g., adult liver transplant NCD 260.1; heart transplant NCD 260.9; intestinal NCD 260.5; islet/pancreas references)

PurposePolicy aligns evaluation and coverage decisions with CMS NCDs and relevant society guidance

Examples citedAdult Liver Transplantation NCD (260.1); Intestinal and Multi-visceral Transplantation NCD (260.5); Heart Transplant NCD (260.9)

Policy Revision History

2026-06-01material_changeLatest

Removed the prior explicit 3-month substance-abuse abstinence requirement for patients with a history of substance misuse as a condition for transplant approval (deletion of criterion 1.A.5).

2026-06-01clarification

Updated background and references to reflect editorial and reference clarifications in the policy document.