Cardiac transplantation is a treatment for many patients with end-stage heart failure (HF) who remain symptomatic despite optimal medical therapy.

A damaged or diseased heart is replaced with a healthy donor heart.

To initiate the prior authorization process, it is necessary to complete and submit the Heart Transplant Request for Coverage Form.

Clinical Guideline Coverage Criteria

The Plan may authorize coverage of a heart transplant for adult and pediatric Members with end-stage heart disease who have satisfactory psychosocial and support systems in place and ONE of the following conditions:

1. Congenital heart disease; or
2. End stage dilated cardiomyopathy refractory to medical therapy; or
3. Myocarditis; or
4. Ischemic cardiomyopathy refractory to medical therapy and not amenable to revascularization procedures; or
5. Non ischemic cardiomyopathy refractory to medical therapy; or

Point32Health companies211630Solid Organ Transplant: Heart

16. Presence of an implanted ventricular assist device; or

7. Severely limiting ischemia not amenable to revascularization procedures; or
8. Valvular heart disease; or
9. Ventricular tachyarrhythmias refractory to all accepted therapeutic modalities

Special Considerations:

Heart-Lung Transplantation:

1. Eisenmenger syndrome with a surgically uncorrectable anomaly and irreversible pulmonary hypertension
2. Pulmonary disease with severe left ventricular failure

Note: A pulmonary diagnosis with severe right heart failure is not an indication for a heart-lung transplant unless accompanied by severe left ventricular failure.

Note: Members >70 years of age may be approved under special circumstances on a case-by-case basis where the Member can be shown to have exceptional pre-morbid performance and has a life expectancy > 5 years. Consideration will occur in the absence of end stage complications of systemic disease such as diabetes mellitus or chronic obstructive lung disease.

Limitations

The Plan will not authorize the coverage of a heart transplant for Members for ANY of the following:

1. Active Hepatitis C
2. Active or uncontrolled alcohol use disorder or substance use disorder
3. Any unresolved psychosocial concerns or history of noncompliance with medical management
4. Clinically severe symptomatic cerebrovascular disease or presence of a recent intra-cranial cerebrovascular event with significant persistent deficit(s)
5. Demonstrated non-compliance, which places the transplanted organ at serious risk of failure
6. Fixed pulmonary hypertension:
   • Pulmonary vascular resistance > 5 Woods units, unresponsive to medical therapy
   • Trans-pulmonary gradient > 15mm/Hg [mean pulmonary artery pressure minus pulmonary capillary wedge pressure]
7. History of malignancy within the past 5 years, including low-grade prostate cancer that has not been ‘cured’ (by prostate-specific antigen measurement), excluding non-melanomatous skin cancers
8. Human immunodeficiency virus (HIV) disease unless ALL of the following are met:
   • CD4 count >200 cells/µL during 3 months prior to transplantation
   • Undetectable HIV-1 ribonucleic acid (RNA)
   • Stable anti-retroviral therapy for > 3 months
   • Absence of serious complications associated with a secondary to HIV disease, (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Karposi’s sarcoma or other neoplasm)
9. Obesity. Patient’s weight over 130% of ideal (BMI 25-28 to encompass NIH and CDI guidelines) or BMI ≥ 35
10. Recurrent infections; uncontrolled or untreated

11. Systemic illness that will limit survival despite heart transplant such as:

11. Systemic lupus erythematosus or sarcoid that has multisystem involvement and is still active
12. Any systemic process with a high probability of recurring in the transplanted heart as determined by the requesting physician

Note: Smoking has been strongly correlated to adverse health and surgical outcomes. There is evidence to show that smoking, both by donors and by recipients, has a major impact on outcomes after organ transplantation. Smoking cessation is strongly recommended for both donors and recipients prior to transplantation.

Codes