A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s) or lobes. Transplantation is an option for individuals with end-stage lung disease.
Lung transplantation may be considered medically necessary for carefully selected individuals with irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximum medical therapy.
A lobar lung transplant from a living or deceased donor may be considered medically necessary for carefully selected individuals with end-stage pulmonary disease.
Lung or lobar lung retransplantation after a failed lung or lobar lung transplant may be considered medically necessary in individuals who meet criteria for lung transplantation.
Lung or lobar lung transplantation not meeting criteria as indicated in this policy is considered not medically necessary.
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 HCV negative adult recipient 18 years of age or older.
32850 |
32851 |
32852 |
32853 |
32854 |
32855 |
32856 |
S2060 |
S2061 |
|
|
|
|
|
The factors below are potential contraindications subject to the judgment of the transplant center for ANY of the following:
Policy Specific:
Patients must meet United Network for Organ Sharing guidelines for a Lung Allocation Score greater than zero (0).
Bilateral lung transplantation is typically required when chronic lung infection and disease is present (ie, associated with cystic fibrosis and bronchiectasis). Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation.
Bronchiolitis obliterans is associated with chronic lung transplant rejection, and thus may be the etiology of a request for lung retransplantation.
Refer to Medical Policy G-17, Outpatient Pulmonary Rehabilitation, for additional information.
Refer to Medical Policy S-125, Heart/Lung Transplantation, for additional information.
International Society for Heart and Lung Transplantation 2021
Initial Transplant
In 2021, the International Society for Heart and Lung Transplantation published updated consensus-based guidelines on the selection of lung transplant candidates. The guidelines states that:
"Lung transplantation should be considered for adults with chronic, end-stage lung disease who meet all thefollowing general criteria:
High (>50%) risk of death from lung disease within 2 years if lung transplantation is not performed.
High (>80%) likelihood of 5-year post-transplant survival from a general medical perspective provided that there is adequate graft function."
The guideline also notes risk factors to be considered in the evaluation of transplant candidates, along with pediatric and disease-specific considerations.
Retransplant
The 2021 guideline update briefly addressed lung retransplantation, with the consensus statement noting that "The outcomes after re-transplants are inferior compared to first lung transplants, particularly if the re-transplant is done within the first year after the original transplant or for patients with restrictive allograft syndrome (RAS) [...] In the pre-transplant evaluation of such patients, particular emphasis should be focused on understanding the possible reasons for the graft failure, such as alloimmunization, poor adherence, gastroesophageal reflux, or repeated infections".
American Thoracic Society et al-2011
Evidence-based recommendations from the American Thoracic Society and 3 international cardiac societies were published in 2011 for the diagnosis and management of individuals with idiopathic fibrosis. For appropriately selected individuals with idiopathic pulmonary fibrosis, the international guideline panel recommended lung transplantation.
An update to this document was published in 2015 in which the committee did not make a recommendation regarding single versus bilateral lung transplantation in patients with idiopathic fibrosis. The committee stated that "it is unclear whether single or bilateral lung transplantation is preferential for long-term outcomes".
In 2014, the American Thoracic Society published guidelines on the management of bronchiolitis obliterans syndrome in lung transplant recipients in conjunction with the International Society for Heart and Lung Transplantation and the European Respiratory Society. The guideline recommends referral to a transplant surgeon to be evaluated for retransplantation for end-stage bronchial obliterans syndrome that is refractory to other therapies.
A15.0 |
C96.5 |
C96.6 |
D48.2 |
D86.0 |
D86.2 |
E71.39 |
E80.3 |
E84.0 |
E84.11 |
E84.19 |
E84.8 |
E84.9 |
E88.01 |
I26.01 |
I26.02 |
I26.09 |
I26.90 |
I26.92 |
I26.93 |
I26.94 |
I26.99 |
I27.0 |
I27.22 |
I27.82 |
I27.83 |
I27.89 |
J42 |
J43.0 |
J43.1 |
J43.2 |
J43.8 |
J43.9 |
J44.0 |
J44.9 |
J47.0 |
J47.1 |
J47.9 |
J44.81 |
J44.89 |
J84.1 |
J84.112 |
J84.178 |
M34.0 |
M34.81 |
P27.0 |
P27.1 |
P27.8 |
P27.9 |
Q33.4 |
T86.811 |
|
|
|
|
|
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.
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:
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.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
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:
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.
