Clinical Policy: Heart-Lung Transplant Form

# Clinical Policy: Heart-Lung Transplant
Reference Number: CP.MP.132  
Date of Last Revision: 04/25  

[See Important Reminder](#important-reminder) at the end of this policy for important regulatory and legal information.  

## Description  
Heart-lung transplantation is the treatment of choice for patients with both end-stage heart and end-stage lung disease. This policy establishes the medical necessity requirements for heart-lung transplants.  

  

## Table 1. New York Heart Association (NYHA) Classifications of Heart Failure¹  
| Classification | Characteristics |  
|----------------|-----------------|  
| Class I        | Patients with cardiac disease but without the resulting limitations in physical activity. Ordinary activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. |  
| Class II       | Patients with heart disease resulting in slight limitations of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain. |  
| Class III      | Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. |  
| Class IV       | Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. The symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases. |  

## Table 2. American Heart Association (AHA) Heart Failure Stages¹  
| Classification | Characteristics |  
|----------------|-----------------|  
| A              | Patients at high risk for heart failure but does not yet have symptoms or structural or functional heart disease. |  
| B              | Patients with no current or previous symptoms of heart failure but have structural heart disease, increased filling pressures in the heart, or other risk factors. |  
| C              | Patients with structural heart disease with current or previous symptoms of heart failure. |  
| D              | Patients who have heart failure with symptoms that interfere with daily life functions or result in recurrent hospitalizations despite continued guideline-directed medical therapy. |  

\*Note: Heart lung transplantations may be considered medically necessary for other congenital cardiopulmonary anomalies as determined upon individual case review.  

## Background  
Heart-lung transplantation is a strong surgical option for selected patients with simultaneous end-stage heart failure and end-stage lung disease. Complex congenital heart disease with Eisenmenger syndrome is the most common indication for heart-lung transplantation, with other common indications to include primary pulmonary hypertension and cystic fibrosis. The frequency of heart-lung transplantation is limited due to the number of suitable donors, while the need for heart-lung transplantation has declined due to the availability of new medical therapies.²  

Contraindications for combined heart-lung transplantation are similar to those for isolated heart and lung transplantation.² The International Society for Heart Lung Transplantation (ISHLT) provides listing criteria and best practice recommendations for heart transplants and for lung transplants.³,⁴,⁵  

According to the 2019 ISHLT registry report, survival rates in adult patients who underwent heart-lung transplantation has steadily improved with an overall median survival rate of 3.7 years from 1992 through 2001 to 6.5 years from 2010 through 2017. This is comparable to primary lung transplantation but is inferior to the median survival rate of heart transplantation alone.²  

## Coding Implications  
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

| CPT® Codes | Description |  
|------------|-------------|  
| 33930      | Donor cardectomy-pneumonectomy (including cold preservation) |  
| 33933      | Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation |  
| 33935      | Heart-lung transplant with recipient cardectomy-pneumonectomy |  

| HCPCS Codes | Description |  
|-------------|-------------|  
| S2152       | Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition |  

## Reviews, Revisions, and Approvals  
| Reviews, Revisions, and Approvals | Revision Date | Approval Date |  
|----------------------------------|---------------|---------------|  
| New policy. References reviewed and updated. Replaced all instances of “member” with “member/enrollee.” | 06/17 | 06/17 |  
| In B.2., removed “adequate functional status with the ability for rehabilitation.” Replaced contraindications of “history of psychological, behavioral, or cognitive disorders, poor family support structures, or documented noncompliance with previous therapies that could interfere with successful performance of care regimens after transplantation” and “current non-adherence to medical therapy…” with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “Review Date” in policy header to “Date of Last Revision” and “Date” in the revision log header to “Revision Date.” | 04/21 | 04/21 |  
| Annual review. References reviewed, updated, and reformatted. Updated 1.C. with some contraindications from ISHLT 2021 guidelines. Background updated with no clinical significance. | 02/22 | 02/22 |  
| Added specific congenital heart disease criteria to 2.i. Removed contraindication regarding specific congenital heart disease lesion. | 05/22 | 05/22 |  
| Annual review completed. Removed pediatric indication of Alpha-1 antitrypsin deficiency. Added “Lung transplantation alone will restore right ventricular function” to 1.C. Updated 1.C.10. to include “unless being considered for multi-organ transplant”. Criteria 1.C.16. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present. ICD-10 diagnosis code table removed. Minor rewording with no clinical significance. References reviewed and updated. External specialists reviewed. | 02/23 | 02/23 |  
| Annual review. Added indication to criteria 1.A.1.j. Expanded criteria 1.C.1. to 1.C.1.a. through j. Removed contraindication 1.C.17., active peptic ulcer disease. References reviewed and updated. | 02/24 | 02/24 |  
| Annual review. Changed 1.A.1. to ≥ 18. 1.A.1.a now reflects “severe” heart failure and 1.A.1.b now reflects “nonspecific idiopathic”. In 1.A.1.h., “non-complex congenital…standard surgery” was removed, and now reflects “Congenital heart disease…”, adding 1.A.1.h.i – iv., followed by i. and j. Age changed to < 18 in 1.A.2 and in 1.A.2.d, added “pulmonary”. Changes made to 1.A.2.h in addition to adding h.i.-v. Ages changed in 1.B.1.a. “≥ 18” and 1.B.1.b. “≤ 18”. In 1.C.1.a, added “for at least …transplantation”. Added 1.C.1.d “Member/enrollee…severe malnutrition”. In 1.C.8., added “unless being…transplant”. Reworded 1.C.16.a. now reflecting “alcohol or illicit drug use”. Table 2 has been changed to the American Heart Association Heart Failure Stages, removing Heart Failure Stages in Pediatric Heart Disease. Background reviewed and updated. Coding verified. Internal and external specialist reviewed. | 02/25 | 02/25 |  
| Updated criteria 1.A.1.h.iv. and 1.A.2.h.iv. from “…could preclude heart failure in the future…” to “…could preclude heart transplant in the future…” | 04/25 | 04/25 |  

  

## Important Reminder  
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.  

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.  

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.  

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.  

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.  

**Note:** For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.  

**Note:** For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.  

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