Transplants Form

1

Transplants - Medical Policy
Updated Revision Effective: February 1, 2025
Policy Number:

UM680POL

Approval Date: 12/19/2024

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Solid organ and bone marrow/stem cell transplants are done to extend and improve the recipient’s quality of life (QOL). The transplants are to replace an end-stage disease with a healthy donor’s organ. Transplant services include non-experimental human organ transplant of an organ or tissue, from one person to another and/or grafting living tissue from its normal site to another location.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. Medicare:  Refer to criteria under the Policy section in this medical policy AND  Health New England follows National Coverage Determinations (NCD) for specific organ transplants https://www.cms.gov/medicare-coverage-database: o 110.23 Stem Cell Transplantation
o 260.9 Heart Transplants o 260.1 Adult Liver Transplantation o 260.2 Pediatric Liver Transplantation o 260.5 Intestinal and Multi-visceral Transplantation o 260.3.1 Islet Cell Transplantation in the Context of a Clinical Trial o 260.3 Pancreas Transplants

2

Policy

I. HNE requires that transplant services for all lines of business, including PPOs, must be provided at a Transplant Center of Excellence (COE). This insures that HNE members receive the highest level of care with the following EXCEPTION:
a. The facility has a contract with HNE to provide specific transplant services.

II. The member must meet the eligibility of the transplant center performing the transplant and be willing and capable of following the post-transplant treatment plan.

III. Medicare Centers of Excellence: Medicare has its own approved network of Centers of Excellence.
These facilities have been approved by the Centers for Medicare and Medicaid Services as meeting institutional coverage criteria. The following NCDs found at https://www.cms.gov/medicare/coverage/approved-facilities-trials-registries will be used for Medicare members requiring transplant:

 NCD 110.23 Stem Cell Transplantation
 NCD 260.9 Heart Transplants  NCD 260.1 Adult Liver Transplantation  NCD 260.2 Pediatric Liver Transplantation  NCD 260.5 Intestinal and Multi-visceral Transplantation  NCD 260.3.1 Islet Cell Transplantation in the Context of a Clinical Trial  NCD 260.3 Pancreas Transplants

IV. HNE covers the following organ transplants when done at Center of Excellence (COE):

1. Lung Transplant (CPT 32850-32856)
2. Autologous and Allogenic bone marrow transplants (CPT 38206, 39240, 38241)
3. Heart transplant (CPT 33940-33945)
4. Heart/lung transplant (CPT 33935, 33945)
5. Kidney transplant (see exception above for non COE)
6. Liver transplant (CPT 47140-47142)
7. Intestinal transplant (CPT 44135-44136)

8. Pancreas transplant (CPT 48550-48556)

   V. Combinations of organs at transplant are reviewed based on each unique organ unless listed in the “What is Not Covered” section of this policy.

   VI. Human Leukocyte Antigen (HLA) testing is covered when necessary to establish bone marrow transplant donor suitability. HNE covers testing for A, B, or DR antigens or any combination thereof.

   VII. If an HNE Member is the recipient of a human organ transplant and the donor’s costs are not covered by any other insurance, HNE will cover the donor charges for no more than 90 days post-operatively or until the HNE Member’s coverage ends, whichever happens first. HNE does not cover the charges for an HNE Member who is donating an organ to a non-HNE member. This applies whether or not the services are covered by the recipient’s plan.

3

V.
What is Not Covered:

A. Treatment at any facility that is not a Center of Excellence except for caveats noted above.
B. Treatment at a non-CMS approved facility.
C. Costs for experimental or unproven procedures. D. When the member is actively abusing alcohol or drugs.
E. Travel and non-medical room and board for a live donor or recipient or for family members of donor or recipient. (For Medicare Advantage transplant services at a distant location, HNE will provide reasonable transportation and accommodations).
F. Artificial or animal-to-human organ or tissue transplant. G. Embryonic stem cell transplants H. Uterine Transplant I. Human leukocyte antigen (HLA) typing of an embryo to identify a future suitable stem cell, tissue or organ transplantation donor is considered experimental and investigational.

Policy Guidelines and Definitions

Definitions:

Center of Excellence: A national certification granted annually by an outside organization to transplanting facilities. Facilities are evaluated on their procedure success and survival rates, the quality of the medical professionals, the number of patients treated with a specific condition, and the program depth and breadth.
Each type of transplant has its own Center of Excellence. A facility may be a Center of Excellence for one type of transplant or several.

Transplant: The non-experimental human organ transplant of an organ or tissue from one person or the grafting of living tissue from its normal position to another site.

Solid Organ Transplant: The transplantation of a kidney, heart, lung, liver, pancreas or intestine.

Blood Marrow / Stem Cell Transplant: There are two types:

1. An autologous transplant is when a person’s blood or stem cells are removed and later given back to that person.

2. An allogenic transplant involves transplanting stem cells or blood from a donor to a recipient.

   Coding Guidance

   CPT Prior Auth Required for all transplants 32850 Donor pneumonectomy(s) (including cold preservation), from cadaver donor 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 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 38206 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection 38214 Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion 38215 Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer

4

38240 Hematopoietic progenitor cell (HPC) allogeneic transplantation per donor
38241 Hematopoietic progenitor cell (HPC) autologous transplantation per donor 33930 Donor cardiectomy-pneumonectomy (including cold preservation) 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy 33940 Donor cardiectomy (including cold preservation) 33944 Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation 33945 Heart transplant, with or without recipient cardiectomy 44132 Donor enterectomy (including cold preservation), open; from cadaver donor 44133 Donor enterectomy (including cold preservation), open; partial, from living donor 44135 Intestinal allotransplantation; from cadaver donor 44136 Intestinal allotransplantation; from living donor 44137 Removal of transplanted intestinal allograft, complete 44715 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein 44720 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each 47133 Donor hepatectomy (including cold preservation), from cadaver donor 44721 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each 47140 Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III) 47141 Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV) 47144 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII]) 47145 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (ie, left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII]) 47143 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split 47147 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each 47142 Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII) 48550 Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation 48551 Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy,

5

ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery. 48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each 48554 Transplantation of pancreatic allograft 48556 Removal of transplanted pancreatic allograft 50300 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral 50320 Donor nephrectomy (including cold preservation); open, from living donor 50323 Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary 50325 Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary 50340 Recipient nephrectomy (separate procedure) 50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy 50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy 50370 Removal of transplanted renal allograft 50547 Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor HPCP

S2140 Cord blood harvesting for transplantation, allogeneic S2142 Cord blood-derived stem-cell transplantation, allogeneic S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; 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 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 S2054 Transplantation of multivisceral organs S2060 Lobar lung transplantation S2061 Donor lobectomy (lung) for transplantation, living donor The following codes are experimental/investigational 0664T Donor hysterectomy (including cold preservation); open, from cadaver donor 0665T Donor hysterectomy (including cold preservation); open, from living donor 0666T Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor 0667T Recipient uterus allograft transplantation from cadaver or living donor 0668T Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary 0669T Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each 0607T Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each

6

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

https://www.cms.gov/medicare/health-safety-standards/certification-compliance/transplant

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 5/2019 Initial effective date 10/2023 NCD’s updated for Transplants. Moved Ventricular Assist Device (VAD) to a separate policy. 1/2024 Added Line of Business section 12/2024 Annual Review. No criteria changes.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare &

7

Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.