Lung transplantation (single or double) may be considered medically necessary for carefully selected adults and children with irreversible, progressively disabling, end-stage pulmonary disease including, but not limited to any ONE of the conditions listed below:

• Alpha-1 antitrypsin deficiency
• Bronchiectasis
• Bronchiolitis obliterans
• Bronchoalveolar carcinoma of the lung (restricted to the lung without sign of spread to mediastinal nodes or other distant sites)
• Bronchopulmonary dysplasia
• Chronic obstructive pulmonary disease
• CREST Syndrome
• Cystic fibrosis  
• Eisenmenger Syndrome
• Emphysema
• Eosinophilic granuloma
• Failed primary lung graft
• Fibrosis, idiopathic pulmonary
• Fibrosis, interstitial pulmonary
• Fibrosis, post-inflammatory
• Graft vs. Host disease 
• Kartagener Syndrome
• Lymphangiomyomatosis
• Pulmonary embolism, recurrent
• Pulmonary hypertension, primary
• Pulmonary hypertension secondary to cardiac disease
• Restrictive pulmonary disease, chemotherapy-induced
• Sarcoidosis
• Scleroderma
• Silicosis
• Systemic Lupus Erythematosus
• Thromboembolic disease

Patient Selection Criteria
In addition, the following individual selection criteria apply:

• Medical therapy has been ineffective or unavailable; and
• Substantial limitation to daily living activities; and
• Ambulatory with rehabilitation potential; and
• Adequate cardiac function without significant coronary artery disease; and
• Acceptable nutritional status; and
• Satisfactory psychosocial profile and emotional support; and
• Individuals must meet United Network for Organ Sharing (UNOS) guidelines for lung allocation score (LAS) greater than zero.

Lung and lobar lung transplantation for all other conditions or for individuals presenting with any absolute contraindication will be considered not medically necessary.

Lobar lung transplant
Lobar lung transplantation may be considered medically necessary for adults and children with end stage pulmonary disease including, but not limited to any ONE of the conditions listed below:

• Alpha-1 antitrypsin deficiency
• Bilateral bronchiectasis
• Bronchiolitis obliterans
• Bronchopulmonary dysplasia
• Chronic obstructive pulmonary disease
• Cystic fibrosis
• Eisenmenger Syndrome
• Emphysema 
• Eosinophilic granuloma
• Pulmonary embolism, recurrent
• Fibrosis, idiopathic pulmonary
• Fibrosis, interstitial pulmonary
• Fibrosis, post-inflammatory
• Lymphangiomyomatosis
• Pulmonary hypertension, primary
• Pulmonary hypertension secondary to cardiac disease
• Sarcoidosis
• Scleroderma

Patient Selection Criteria
In addition, the following individual selection criteria apply:

• Medical therapy has been ineffective or unavailable; and
• Substantial limitation to daily living activities; and
• Ambulatory with rehabilitation potential; and
• Adequate cardiac function without significant coronary artery disease; and
• Acceptable nutritional status; and
• Satisfactory psychosocial profile and emotional support; and
• Patients must meet UNOS guidelines for lung allocation score (LAS) greater than zero.

Lung and lobar lung transplantation for all other conditions will be considered not medically necessary.

Absolute contraindications for transplant recipients include, but are not limited to, the following:

• Metastatic cancer; or
• Ongoing or recurring infections that are not effectively treated; or
• Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery; or
• Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured; or
• Demonstrated individual noncompliance, which places the organ at risk by not adhering to medical recommendations; or
• Potential complications from immunosuppressive medications are unacceptable to the individual; or
• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy; or
• AIDS (diagnosis based on CDC definition of CD4 count, 200cells/mm3) unless the following are noted:
  • CD4 count greater than 200 cells/mm³ for greater than six (6) months; and
  • HIV-1 RNA undetectable; and
  • On stable anti-retroviral therapy greater than three (3) months; and
  • No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi's sarcoma or other neoplasm); and
  • Meeting all other criteria for lung and lobar transplantation.

Lung and lobar lung transplantation for individuals presenting with any absolute contraindication will be considered not medically necessary.

Relative contraindications for lung and lobar transplantation include, but are not limited to, the following:

• History of cancer with a moderate risk of recurrence; or
• Systemic disease that could be exacerbated by immunosuppression; or
• Psychosocial conditions or chemical dependence affecting the ability to adhere to therapy; or
• Coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function; or
• Colonization with highly resistant or highly virulent bacteria, fungi or mycobacteria.

Lung and lobar transplantation for individuals presenting with a relative contraindication will be reviewed on a case-by-case basis.

Retransplantation in individuals with graft failure of an initial lung or lobar transplant, due to either technical reasons or hyperacute rejection may be considered medically necessary.

Retransplantation in individuals with chronic rejection or recurrent disease may be considered medically necessary when the individual meets the indications and limitations of coverage.

Retransplantation in individuals with bronchiolitis obliterans may be considered medically necessary as it is associated with chronic lung transplant rejection, and thus, may be the etiology of a request for lung retransplantation.

Selected candidates may be eligible for multi-organ transplant. In each case, the candidate should meet all of the indications and limitations of coverage for the individual transplant.

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

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