Humana Solid Organ Transplants Form

. Description Solid organ transplantation includes pre-transplant, transplant and post-discharge services, including the treatment of complications. Allogeneic islet cell transplants obtain islet cells from another individual for use in the affected person. Allogeneic islet cell transplants are performed in an individual with type 1 diabetes mellitus with the key goal being to eliminate the need for insulin administration. (Refer to Coverage Limitations section) Autologous islet cell transplants are those obtained from and used in the individual’s own body, which are utilized to reduce the incidence of diabetes mellitus in an individual who have undergone a total or near total pancreatectomy due to chronic pancreatitis. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 2 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Cardiopulmonary (heart and lung) transplants may be performed in an individual with end-stage lung disease that affects the heart (eg, severe pulmonary hypertension). Heart transplants may be performed in an individual with irreversible heart damage. Intestinal transplants may be performed in an individual with chronic, irreversible intestinal failure. The transplant allows the individual to become independent of total parenteral nutrition, restores vitamin and nutrient absorption of the small bowel and allows the individual to resume more normal eating habits. There are three categories of intestinal transplantation: intestine-alone transplant, intestine- liver transplant and one that includes stomach, duodenum and pancreas along with the small intestine and liver, which is also known as a multivisceral transplant.127 Kidney transplants may be performed to provide a healthy kidney for an individual with kidney failure. The transplant may be from a cadaver donor or from a living donor. Liver transplants may be performed in pediatric or adult individual with end-stage liver disease using a healthy liver graft from a donor. The transplant may be from a cadaver donor or a portion from a healthy living donor. Living-related donor segmental pancreas transplants may be performed in order to reduce waiting time for a matched cadaveric organ, to enhance immunologic compatibility and decrease cold ischemic injuries to the donated organ. (Refer to Coverage Limitations section) Lung transplants involve the transplantation of a lung lobe or lobes, to replace the diseased lung(s) of individuals with end stage lung disease. The transplant may be from a cadaver donor or from a living donor. Multivisceral transplants may be performed in an individual who suffer from a loss of organ function due to injury or who have chronic gastrointestinal problems that have resulted in the failure of other organs. Multivisceral organ transplants include the small bowel and liver and can include the stomach, duodenum, jejunum, ileum, pancreas or colon. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 3 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Pancreas after kidney (PAK) transplants may be performed in an individual with type 1 diabetes mellitus who have already had a successful kidney transplant to treat diabetic renal insufficiency. The goal of PAK transplantation is to prevent, slow or reverse additional secondary diabetic complications, including retinopathy, neuropathy and vasculopathy.65 Pancreas transplants may be performed in an individual who are nonuremic or preuremic with type 1 diabetes mellitus with the goal of improving quality of life by eliminating the need for exogenous insulin and its associated problems with imperfect glucose control and preventing or reversing secondary diabetic complications. Simultaneous pancreas/kidney (SPK) transplants may be performed to correct complications from type 1 diabetes mellitus. Complications of type 1 diabetes mellitus may include severe impairment of glucose metabolism, increased need for exogenous insulin, renal failure, dialysis, neuropathy, retinopathy and vascular disease. Organ preservation systems are utilized for maintaining organ viability after removal from the donor and during transport for transplantation. These systems include, but may not be limited to, the following: Ex Vivo Lung, Kidney Assist, Organ Care System (OCS Heart, OCS Liver, OCS Lung), OrganOx metra System, and RM3 Kidney Perfusion System. (Refer to Coverage Limitations section) For information regarding uterine transplants, please refer to Infertility Evaluation and Treatment Medical Coverage Policy. Coverage Determination Renal autotransplantation, reimplantation of the kidney follow normal clinical review processes and are not managed by the Humana Transplant Department. Humana members may be eligible under the Plan for transplant evaluation for any diagnosis to determine the medical necessity for a solid organ transplant. Humana members may be eligible under the Plan for the following solid organ transplants: See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 4 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. • Autologous islet cell • Cardiopulmonary (heart and lung) • Heart • Intestinal • Kidney (living or cadaver) • Liver (living or cadaver) • Lung • Multivisceral • Pancreas (includes PAK and SPK) Humana members and their donors may be eligible under the Plan for the treatment of living donor complications for the following indications: • Complications have occurred within 1 year from donation; AND • Complications cause a functional impairment and are reasonably expected as a result of being a living donor (eg, incisional hernia or infection); AND • Recipient’s certificate contains donor benefits that allows for living donations If treatment is part of a clinical trial, please refer to Clinical Trials Medical Coverage Policy. Coverage Limitations Humana members may NOT be eligible under the Plan for allogeneic islet cell transplants. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language. Humana members may NOT be eligible under the Plan for living-related donor segmental pancreas transplants. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language. Humana members may NOT be eligible under the Plan for organ preservation systems. This is considered experimental/investigational as it is not identified as See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 5 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language. Background Additional information about solid organ transplants may be found from the following websites: • National Library of Medicine Medical Alternatives To make the best health decision for the patient’s individual needs, the patient should consult his/her physician. Provider Claims Codes Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure. CPT® Code(s) 32850 32851 32852 32853 32854 Description Comments Donor pneumonectomy(s) (including cold preservation), from cadaver donor Lung transplant, single; without cardiopulmonary bypass Lung transplant, single; with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass 32999 Unlisted procedure, lungs and pleura 33935 33945 Heart-lung transplant with recipient cardiectomy- pneumonectomy Heart transplant, with or without recipient cardiectomy Not Covered if used to report any procedure outlined in Coverage Limitations section See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 6 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Not Covered if used to report any procedure outlined in Coverage Limitations section Not Covered if used to report any procedure outlined in Coverage Limitations section Not Covered if used to report any procedure outlined in Coverage Limitations section 33999 Unlisted procedure, cardiac surgery 44135 44136 47133 47135 Intestinal allotransplantation; from cadaver donor Intestinal allotransplantation; from living donor Donor hepatectomy (including cold preservation), from cadaver donor Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age 47399 Unlisted procedure, liver 48160 48550 48554 48556 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft 48999 Unlisted procedure, pancreas 50300 50320 50340 50360 50365 50370 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral Donor nephrectomy (including cold preservation); open, from living donor Recipient nephrectomy (separate procedure) Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Removal of transplanted renal allograft See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 7 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 50547 Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor 53899 Unlisted procedure, urinary system Not Covered if used to report any procedure outlined in Coverage Limitations section CPT® Category III Code(s) 0494T 0495T 0496T Description Comments Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; each additional hour (List separately in addition to code for primary procedure) Not Covered Not Covered Not Covered 0584T Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 8 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open Description Comments Percutaneous islet cell transplant, includes portal vein catheterization and infusion Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion Laparotomy for islet cell transplant, includes portal vein catheterization and infusion Transplantation of small intestine and liver allografts Transplantation of multivisceral organs Lobar lung transplantation Simultaneous pancreas kidney transplantation Islet cell tissue transplant from pancreas; allogeneic Transplant related lodging, meals and transportation, per diem Not Covered 0585T 0586T HCPCS Code(s) G0341 G0342 G0343 S2053 S2054 S2060 S2065 S2102 S9975 References 1. 2. American Academy of Pediatrics (AAP). Policy Statement. Pediatric organ donation and transplantation. https://www.aap.org. Published April 2010. Accessed April 11, 2023. American Association for the Study of Liver Diseases (AASLD). AASLD Position Paper. Introduction to the revised American Association for the Study of Liver Diseases position paper on acute liver failure 2011. https://www.aasld.org. Published March 2012. Accessed April 10, 2023. 3. American Association for the Study of Liver Diseases (AASLD). Diagnosis and management of autoimmune hepatitis in adults and children: 2019 practice guidance and guidelines from the American Association for the Study of Liver See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 9 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 4. 5. 6. 7. 8. 9. Diseases. https://www.aasld.org. Published August 25, 2020. Accessed April 7, 2023. American Association for the Study of Liver Diseases (AASLD). Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. https://www.aasld.org. Published July 2011. Accessed April 7, 2023. American Association for the Study of Liver Diseases (AASLD). Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American Association for the Study of Liver Diseases. https://www.aasld.org. Published January 21, 2020. Accessed April 7, 2023. American Association for the Study of Liver Diseases (AASLD). Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. https://www.aasld.org. Published August 2021. Accessed April 10, 2023. American Association for the Study of Liver Diseases (AASLD). Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. https://www.aasld.org. Published August 2018. Accessed April 7, 2023. American Association for the Study of Liver Diseases (AASLD). Evaluation for liver transplantation in adults: 2013 practice guideline by the AASLD and the American Society of Transplantation. https://www.aasld.org. Published March 2014. Accessed April 7, 2023. American Association for the Study of Liver Diseases (AASLD). Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. https://www.aasld.org. Published July 2014. Accessed April 7, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 10 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 10. American Association for the Study of Liver Diseases (AASLD). Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. https://www.aasld.org. Published August 2014. Accessed April 7, 2023. 11. American Association for the Study of Liver Diseases (AASLD). Hepatitis C guidance 2019 updated: American Association for the Study of Liver Diseases- Infectious Disease Society of American recommendations for testing, managing and treating hepatitis C virus infection. https://www.aasld.org. Published February 2020. Accessed April 7, 2023. 12. American Association for the Study of Liver Diseases (AASLD). Practice Guidance. AASLD practice guideline on primary sclerosing cholangitis and cholangiocarcinoma. https://www.aasld.org. Published February 2010. Updated February 2023. Accessed April 7, 2023. 13. American Association for the Study of Liver Diseases (AASLD). Practice Guideline. AASLD practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. https://www.aasld.org. Published January 2018. Updated 2023. Accessed April 7, 2023. 14. American Association for the Study of Liver Diseases (AASLD). Practice Guideline. A multidisciplinary approach to the diagnosis and management of Wilson disease: 2022 practice guidance on Wilson disease from the American Association for the Study of Liver Diseases. https://www.aasld.org. Published June 2008. Accessed April 7, 2023. 15. American Association for the Study of Liver Diseases (AASLD). Primary biliary cholangitis: 2018 practice guidance from the American Association for the Study of Liver Diseases. https://www.aasld.org. Published 2018. Accessed April 7, 2023. 16. American Association for the Study of Liver Diseases (AASLD). Primary biliary cholangitis: 2021 practice guidance update from the American Association for the Study of Liver Diseases. https://www.aasld.org. Published 2018. Accessed April 7, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 11 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 17. American Association for the Study of Liver Diseases (AASLD). Update on prevention, diagnosis, and treatment of chronic hepatitis b: AASLD 2018 hepatitis b guidance. https://www.aasld.org. Published April 2018. Accessed April 7, 2023. 18. American Association for the Study of Liver Diseases (AASLD). Vascular liver disorders, portal vein thrombosis, and procedural bleeding in patients with liver disease: 2020 practice guidance by the American Association for the Study of Liver Diseases. https://www.aasld.org. Published January 2021. Accessed April 7, 2023. 19. American College of Cardiology (ACC). 2018 AHA/ACC guideline for the management of adults with congenital heart failure disease. https://www.acc.org. Published April 2, 2019. Accessed April 6, 2023. 20. American College of Cardiology (ACC). 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. https://www.acc.org. Published December 22, 2020. Accessed April 6, 2023. 21. American College of Cardiology (ACC). 2022 AHA/ACC/HFSA guideline for the management of heart failure. https://www.acc.org. Published 2022. Accessed April 6, 2023. 22. American College of Gastroenterology (ACG). ACG clinical guideline: acute-on- chronic liver failure clinical guidelines. https://www.gi.org. Published February 2022. Accessed April 10, 2023. 23. American College of Gastroenterology (ACG). ACG clinical guideline: alcoholic liver disease. https://www.gi.org. Published February 2018. Accessed April 10, 2023. 24. American College of Gastroenterology (ACG). ACG clinical guideline: diagnosis and management of idiosyncratic drug-induced liver injury. https://www.gi.org. Published May 2021. Accessed April 10, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 12 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 25. American College of Gastroenterology (ACG). ACG clinical guideline: evaluation of abnormal liver chemistries. https://www.gi.org. Published January 2017. Accessed April 10, 2023. 26. American College of Gastroenterology (ACG). ACG clinical guideline: primary sclerosing cholangitis. https://www.gi.org. Published May 2015. Accessed April 10, 2023. 27. American College of Gastroenterology (ACG). ACG clinical guideline: the diagnosis and management of focal liver lesions. https://www.gi.org. Published September 2014. Accessed April 10, 2023. 28. American College of Radiology (ACR). ACR Appropriateness Criteria. Management of liver cancer. https://www.acr.org. Published 2022. Accessed April 12, 2023. 29. American Gastroenterological Association (AGA). American Gastroenterological Association Institute guidelines for the diagnosis and management of acute liver failure. https://www.gastro.org. Published February 2017. Accessed April 10, 2023. 30. American Thoracic Society (ATS). An official American Thoracic Society clinical practice guideline: classification, evaluation and management of childhood interstitial lung disease in infancy. https://www.thoracic.org. Published 2013. Accessed April 12, 2023. 31. American Thoracic Society (ATS). An official ATS/ERS/JRS/ALAT clinical practice guideline: treatment of idiopathic pulmonary fibrosis. An update of the 2011 clinical practice guideline. https://www.thoracic.org. Published July 15, 2015. Accessed April 12, 2023. 32. American Thoracic Society (ATS). Guideline. Pediatric pulmonary hypertension. https://www.thoracic.org. Published November 24, 2015. Accessed April 12, 2023. 33. American Thoracic Society (ATS). Lymphangioleiomyomatosis diagnosis and management: high-resolution chest computed tomography, transbronchial lung biopsy and pleural disease management. An official American Thoracic See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 13 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Society/Japanese Respiratory Society clinical practice guideline. https://www.thoracic.org. Published August 2017. Accessed April 12,2023. 34. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Adult liver transplantation (260.1). https://www.cms.gov. Published June 21, 2012. Accessed April 7, 2023. 35. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Heart transplants (260.9). https://www.cms.gov. Published May 1, 2008. Accessed April 7, 2023. 36. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Intestinal and multi-visceral transplantation (260.5). https://www.cms.gov. Published May 11, 2006. Accessed April 7, 2023. 37. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Islet cell transplantation in the context of a clinical trial (260.3.1). https://www.cms.gov. Published October 4, 2004. Accessed April 12, 2023. 38. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Pancreas transplants (260.3). https://www.cms.gov. Published April 26, 2006. Accessed April 7, 2023. 39. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Pediatric liver transplantation (260.2). https://www.cms.gov. Published April 12, 1991. Accessed April 7, 2023. 40. ClinicalKey. Carrion AF, Martin P. Cirrhosis. In: Ferri F. Ferri’s Clinical Advisor 2023. Elsevier; 2023:196-206.e1. https://www.clinicalkey.com. Accessed March 31, 2023. 41. ClinicalKey. Crandall JP, Shamoon H. Diabetes mellitus. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:1490-1510.e3. https://www.clinicalkey.com. Accessed March 31, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 14 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 42. ClinicalKey. Dutta, R. Cor pulmonale. In: Ferri F. Ferri’s Clinical Advisor 2023. Elsevier; 2023:435-437.e1. https://www.clinicalkey.com. Accessed March 31, 2023. 43. ECRI Institute. Clinical Evidence Assessment. Ex vivo lung perfusion for preserving donated lungs. https://www.ecri.org. Published February 10, 2023. Accessed March 28, 2023. 44. ECRI Institute. Clinical Evidence Assessment. Metra perfusion system (OrganOx Ltd.) for preserving donor livers. https://www.ecri.org. Published March 3, 2020. Updated October 8, 2021. Accessed March 28, 2023. 45. ECRI Institute. Clinical Evidence Assessment. Organ Care System Lung (TransMedics, Inc.) for preserving donor lungs. https://www.ecri.org. Published August 15, 2012. Updated July 23, 2021. Accessed March 28, 2023. 46. ECRI Institute. Product Brief. Lung Assist perfusion system (Organ Assist Products B.V.) for preserving donated lungs. https://www.ecri.org. Published January 13, 2020. Accessed March 28, 2023. 47. ECRI Institute. Product Brief. Organ Care System (OCS) liver perfusion system (TransMedics, Inc.) for preserving donor livers. https://www.ecri.org. Published February 1, 2020. Accessed March 28, 2023. 48. ECRI Institute. Product Brief. RM3 Kidney Perfusion System (Waters Medical Systems) for preserving donor kidneys. https://www.ecri.org. Published January 13, 2020. Accessed March 28, 2023. 49. ECRI Institute. Product Brief. XVIVO Perfusion System with STEEN solution perfusate (XVIVO Perfusion, Inc.) for preserving donor lungs. https://www.ecri.org. Published July 9, 2019. Accessed March 28, 2023. 50. ECRI Institute. Technology Forecast. Organ Care System (OCS) to treat end- stage heart failure requiring transplantation. https://www.ecri.org. Published September 22, 2021. Accessed March 28, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 15 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 51. Hayes, Inc. Emerging Technology Report. Organ Care System (OCS) heart. https://evidence.hayesinc.com. Published September 9, 2021. Updated May 11, 2022. Accessed March 28, 2023. 52. Hayes, Inc. Emerging Technology Report. Organ Care System (OCS) liver. https://evidence.hayesinc.com. Published January 19, 2022. Accessed April 18, 2023. 53. Hayes, Inc. Emerging Technology Report (ARCHIVED). Organ Care System (OCS) lung. https://evidence.hayesinc.com. Published April 29, 2019. Accessed March 28, 2023. 54. Hayes, Inc. Evidence Analysis Research Brief. Simultaneous pancreas kidney (SPK) transplant in adults with HIV and type 1 or type 2 diabetes. https://evidence.hayesinc.com. Published February 9, 2023. Accessed March 29, 2023. 55. Hayes, Inc. Emerging Technology Report (ARCHIVED). XVIVO Perfusion System (XPS) with steen solution. https://evidence.hayesinc.com. Published January 4, 2017. Accessed March 28, 2023 56. Hayes, Inc. Health Technology Assessment (ARCHIVED). Lung transplantation. https://evidence.hayesinc.com. Published November 5, 2009. Updated December 31, 2012. Accessed March 28, 2023. 57. Hayes, Inc. Health Technology Brief (ARCHIVED). Living related donor small bowel transplantation for intestinal failure. https://evidence.hayesinc.com. Published June 26, 2014. Updated April 22, 2016. Accessed March 28, 2023. 58. Hayes, Inc. Medical Technology Directory (ARCHIVED). Islet cell transplantation for the treatment of type 1 diabetes. https://evidence.hayesinc.com. Published August 1, 2004. Updated July 21, 2009. Accessed March 28, 2023. 59. Hayes, Inc. Medical Technology Directory (ARCHIVED). Liver transplantation, adult. https://evidence.hayesinc.com. Published July 10, 2002. Updated July 29, 2007. Accessed March 28, 2023. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 16 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 60. Hayes, Inc. Medical Technology Directory (ARCHIVED). Liver transplantation for obese adults. https://evidence.hayesinc.com. Published January 30, 2009. Updated February 18, 2011. Accessed March 28, 2023. 61. Hayes, Inc. Medical Technology Directory (ARCHIVED). Liver transplantation, pediatric. https://evidence.hayesinc.com. Published July 6, 2002. Updated July 31, 2007. Accessed March 28, 2023. 62. Hayes, Inc. Medical Technology Directory (ARCHIVED). Living donor liver transplantation. https://evidence.hayesinc.com. Published May 22, 2002. Updated Mar 20, 2007. Accessed March 28, 2023. 63. Hayes, Inc. Medical Technology Directory (ARCHIVED). Living donor lobar lung transplantation. https://evidence.hayesinc.com. Published May 2, 2003. Updated April 14, 2008. Accessed March 28, 2023. 64. Hayes, Inc. Medical Technology Directory (ARCHIVED). Living-related donor segmental pancreas transplantation. https://evidence.hayesinc.com. Published April 13, 2002. Updated April 19, 2007. Accessed March 28, 2023. 65. Hayes, Inc. Medical Technology Directory (ARCHIVED). Pancreas-after-kidney (PAK) transplantation in diabetic patients. https://evidence.hayesinc.com. Published June 30, 2006. Updated June 24, 2010. Accessed March 28, 2023. 66. Hayes, Inc. Medical Technology Directory (ARCHIVED). Pancreas transplant alone (PTA). https://evidence.hayesinc.com. Published February 27, 2006. Updated March 19, 2010. Accessed March 28, 2023. 67. Hayes, Inc. Medical Technology Directory (ARCHIVED). 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Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 69. Hayes, Inc. Medical Technology Directory (ARCHIVED). Total pancreatectomy with islet autotransplantation for chronic pancreatitis. https://evidence.hayesinc.com. Published December 22, 2015. Updated January 17, 2020. Accessed March 28, 2023. 70. 71. 72. 73. International Society for Heart and Lung Transplantation (ISHLT). 2019 updated consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension: the European Pediatric Pulmonary Vascular Disease Network (EPPVDN), endorsed by AEPC, ESPR and ISHLT. https://www.ishlt.org. Published September 2019. Accessed April 12, 2023. International Society for Heart and Lung Transplantation (ISHLT). Consensus Statement. A consensus document for the selection of lung and transplant candidates: an update from the International Society for Heart and Lung Transplantation. https://www.ishlt.org. Published November 2021. 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All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 18 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 77. MCG Health. Liver transplant, pediatric. 26th edition. https://www.mcg.com. Accessed March 7, 2023. 78. MCG Health. Lung transplant. 26th edition. https://www.mcg.com. Accessed March 7, 2023. 79. MCG Health. Lung transplant, pediatric. 26th edition. https://www.mcg.com. Accessed March 7, 2023. 80. MCG Health. Renal transplant. 26th edition. https://www.mcg.com. Accessed March 7, 2023. 81. 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Wilms tumor and other childhood kidney tumors treatment (PDQ) – health professional version. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 19 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. https://www.cancer.gov. Updated December 23, 2022. Accessed April 11, 2023. 88. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Bilary Tract Cancers. https://www.nccn.org. Published March 10, 2023. Accessed April 11, 2023. 89. 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All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Solid Organ Transplants Effective Date: 04/27/2023 Revision Date: 04/27/2023 Review Date: 04/27/2023 Policy Number: HUM-0467-018 Page: 23 of 24 Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. 123. UpToDate, Inc. Management of refractory chronic obstructive pulmonary disease. https://www.uptodate.com. Updated March 10, 2023. Accessed March 29, 2023. 124. UpToDate, Inc. Management of the short bowel syndrome in adults. https://www.uptodate.com. Updated February 6, 2023. Accessed March 29, 2023. 125. UpToDate, Inc. 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All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only.