Clinical Policy: Lung Transplantation Form
CENTENE Corporation
Clinical Policy: Lung Transplantation Reference Number: CP.MP.57 Date of Last Revision: 02/25
See Important Reminder at the end of this policy for important regulatory and legal information.
Description This policy describes the medical necessity criteria for the review of lung transplantation requests.
The below criteria are sourced from the International Society for Heart and Lung Transplantation (ISHLT) 2021 Consensus Document for the Selection of Lung Transplant Candidates.¹
The ISHLT consensus document that the below criteria are derived from provides guidelines based on expert synthesis of the current literature with a goal of improving survival and quality of life in transplant candidates. ISHLT recognizes that donor lungs are a limited societal resource, requiring that guidance on candidate selection be based on survival benefit. Given the rigor of the guidelines on which this policy is based, the benefits of receiving a lung transplant, as applicable) in individuals meeting the criteria below outweighs the potential risk of adverse outcomes related to receiving a transplant that is not indicated or not receiving a transplant that is indicated.
Note: For criteria applicable to Medicare plans, please see MC.CP.MP.57 Lung Transplantation.
Policy/Criteria
*Note: FVC may be a less reliable parameter for those with concomitant emphysema.¹
Background Lung transplantation is an accepted therapy for the management of a range of severe lung disorders. Single, double, and lobar-lung transplants have all been successful for carefully selected patients with end-stage pulmonary disease. The most common disease processes for which lung transplants are performed include chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, pulmonary arterial hypertension, and sarcoidosis.⁵
COPD is one of the most common lung diseases and is the most common indication for lung transplantation in adults. Chronic bronchitis and emphysema are the two main forms of COPD, both most commonly caused by smoking. Non-smokers with an alpha-1 antitrypsin deficiency can also develop emphysema. These conditions are the most common indications for single lung transplants. Cystic fibrosis, emphysema, and alpha-1 antitrypsin deficiency are the most common indications for double lung transplant, or sequential replacement of both lungs.
The most common indications for pediatric lung transplants include pulmonary vascular disease, bronchiolitis obliterans, bronchopulmonary dysplasia, graft failure due to viral pneumonitis, and cystic fibrosis.
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 |
|---|---|
| 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 (bilateral sequential or en bloc); without cardiopulmonary bypass |
| 32854 | Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass |
| 32855 | Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral |
| 32856 | Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral |
| HCPCS Codes | Description |
|---|---|
| S2060 | Lobar lung transplantation |
| 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 post-transplant care in the global definition |
| Reviews, Revisions, and Approvals | Revision Date | Approval Date |
|---|---|---|
| Policy developed. Specialist review. | 01/14 | 02/14 |
| Replaced contraindications of “severely limited functional status with poor rehabilitation potential” and those regarding past or current nonadherence to medical therapy, and psychological condition associated with the inability to comply with medical therapy with “Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.” Changed “review date” in header to “Date of Last Revision” and “Date” in the revision log header to “Revision | 08/21 | 08/21 |
| Date.” | ||
| Annual review. References reviewed and updated. Reviewed by specialist. | 09/21 | 09/21 |
| Annual review. Added “or surgical therapy” to I and noted that maximal medical therapy includes pulmonary rehab when applicable. Updated the following based on ISHLT 2021 guidelines; removed criteria “High (> 80%) likelihood of surviving at least 90 days after lung transplantation.” updated I.C.1.a, I.D.1.a, I.D.1.b., I.D.1.c., I.D.1.d., I.D.1.f., I.D.2.a., I.D.2.b. Clarified nicotine and tobacco abstinence contraindication. Added CPT codes 32850, 32855, and 32856. References reviewed, updated, and reformatted. Reviewed by specialist. | 02/22 | 02/22 |
| Annual review. Criteria I.C.14. 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. Added pediatric indication for end-stage emphysema due to alpha-1 trypsin deficiency. ICD-10 codes removed. References reviewed and updated. Reviewed by external specialist. | 02/23 | 02/23 |
| Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated. | 08/23 | 08/23 |
| Added note to policy to refer to MC.CP.MP.57 for Medicare criteria. | 11/23 | |
| Added “non-Medicare” to health plans in Policy/Criteria I. | ||
| Annual review. Updated I.C.2. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2. Expanded I.C.9. with qualifying criteria for members who are HIV positive. Updated I.D.2.a.1. from FEV1<25% to FEV1<30%. Background updated with no impact to criteria. References reviewed and updated. | 04/24 | 04/24 |
| Annual review. Updated glomerular filtration rate from < 30 to < 40 mL/min/1.73m2 in Criteria I.C.2. Updated Criteria I.C.9.a. to include at least three months prior to transplantation. Removed additional information regarding heart transplant waiting list in Criteria I.C.9.b. Minor grammatical update in Criteria I.C.9.c. Added Criteria I.C.9.d. regarding chronic wasting or severe malnutrition. Expanded Criteria I.C.13. regarding active substance use or dependence and added Criteria I.C.14. regarding documentation of abstinence from substance use. Minor grammatical changes to Criteria I.D.1.b.ii.b)5), Criteria I.D.1.c.i., Criteria I.D.2., Criteria I.D.2.a.ii.b)5), Criteria I.D.2.d.i. with no clinical significance. Added Criteria I.D.2.h., Criteria I.D.2.i., Criteria I.D.2.j. regarding alveolar capillary dysplasia, pulmonary vein stenosis refractory to intervention, and pulmonary veno-occlusive disease. Background updated with no impact to criteria. References reviewed and updated. Reviewed by internal specialist and external specialist. | 02/25 | 02/25 |
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
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