HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
S-122-009
Topic:
Heart Transplantation
Section:
Surgery
Effective Date:
July 1, 2019
Issued Date:
July 1, 2019
Last Revision Date:
June 2019
Annual Review:
November 2018
 
 

Heart transplantation consists of replacing a diseased heart with a healthy donor heart. It is used for individuals with refractory end-stage cardiac disease.

Policy Position

Heart transplantation may be considered medically necessary for selected adults with end-stage heart failure when individual selection criteria are met.

Adult Individuals - Accepted Indications for Heart Transplantation

Hemodynamic compromise due to heart failure demonstrated by ANY ONE of the following: 

  • Maximal VO2 (oxygen consumption) less than 10 mL/kg/min with achievement of anaerobic metabolism; or
  • Refractory cardiogenic shock; or
  • Documented dependence on intravenous inotropic support to maintain adequate organ perfusion; or

Severe ischemia consistently limiting routine activity not amenable to bypass surgery or angioplasty; or

Recurrent symptomatic ventricular arrhythmias refractory to ALL accepted therapeutic modalities.

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Adult Individuals - Probable Indications for Heart Transplantation

Maximal VO2 less than 14 mL/kg/min and major limitation of the individual's activities; or

Recurrent unstable ischemia not amenable to bypass surgery or angioplasty; or

Instability of fluid balance/renal function not due to individual non-compliance with regimen of weight monitoring, flexible use of diuretic drugs, and salt restriction.

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Adult Individuals - Inadequate Indications for Heart Transplantation

Unless other factors as listed above are present, the following conditions are considered not medically necessary:

  • Ejection fraction less than 20%; or
  • History of functional class III or IV symptoms of heart failure; or
  • Previous ventricular arrhythmias; or
  • Maximal VO2 greater than 15 mL/kg/min.

Heart transplantation for all other adult conditions is considered not medically necessary.

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Heart transplantation may be considered medically necessary for selected children with end-stage heart failure when individual selection criteria are met.

Pediatric Individuals - Accepted Indications for Heart Transplantation

Heart failure with persistent symptoms at rest who require at least ONE of the following:

  • Continuous infusion of intravenous inotropic agents; or
  • Mechanical ventilator support; or
  • Mechanical circulatory support; or

Heart disease with symptoms of heart failure who do not meet the above criteria but who have at least ONE of the following:

  • Severe limitation of exercise and activity (if measurable, such individuals would have a peak maximum oxygen consumption less than 50% predicted for age and sex); or
  • Cardiomyopathies or previously repaired or palliated congenital heart disease and significant growth failure attributable to the heart disease; or
  • Near sudden death and/or life-threatening arrhythmias untreatable with medications or an implantable defibrillator; or
  • Restrictive cardiomyopathy with reactive pulmonary hypertension; or
  • Reactive pulmonary hypertension and potential risk of developing fixed, irreversible elevation of pulmonary vascular resistance that could preclude orthotopic heart transplantation in the future; or
  • Anatomical and physiological conditions likely to worsen the natural history of congenital heart disease in infants with a functional single ventricle; or
  • Anatomical and physiological conditions that may lead to consideration for heart transplantation without systemic ventricular dysfunction. 

Pediatric Individuals - Inadequate Indications for Heart Transplantation

Heart transplantation for all other pediatric conditions is considered not medically necessary.

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Potential Contraindications

The following conditions represent potential contraindications to heart transplantation subject to the judgement of the transplant center:

  • Pulmonary hypertension that is fixed as evidenced by pulmonary vascular resistance (PVR) greater than 5 Wood units, or transpulmonary gradient (TPG) greater than or equal to 16 mm/Hg despite treatment; or
  • Severe pulmonary disease despite optimal medical therapy, not expected to improve with heart transplantation; or
  • Known current malignancy, including metastatic cancer; or
  • Recent malignancy with high risk of recurrence; or
  • Untreated systemic infection making immunosuppression unsafe, including chronic infection; or
  • Other irreversible end-stage disease not attributed to heart or lung disease; or
  • History of cancer with a moderate risk of recurrence; or
  • Systemic disease that could be exacerbated by immunosuppression; or
  • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

Conditions determined to be a contraindication to heart transplantation are considered not medically necessary.

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Re-transplantation

Heart re-transplantation after a failed primary heart transplant may be considered medically necessary in individuals who meet criteria for heart transplantation. 

Heart re-transplantation after a failed primary heart transplant is considered not medically necessary in individuals who do not meet criteria for heart transplantation.

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In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

Related Policies

Refer to medical policy S-125, Heart/Lung Transplantation, for additional information.


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Place of Service: Inpatient


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.