Point32 Solid Organ Transplant: Lung Form

A lung transplant is surgery to replace one or both diseased lungs with healthy ones from a human donor.

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

Clinical Guideline Coverage Criteria

Indications for lung transplant include pulmonary disease such as, but not limited to the following:

• alpha-1-antitrypsin deficiency,
• advanced obstructive lung disease,
• pulmonary hypertension,
• Bronchopulmonary dysplasia,
• cystic fibrosis,
• interstitial lung disease (ILD),
• Lymphangioleiomyomatosis,
• sarcoidosis,
• Eisenmenger's syndrome, and
• severe bronchiectasis.

In general, transplant recipients over the age of 70 years have an increased likelihood for poor outcome and worse long-term survival compared to younger recipients.

The Plan may authorize a lung transplant for Members with chronic end stage pulmonary disease when ALL of the following are met:

1. The Member has clinically and physiologically irreversible disease unresponsive to maximum medical or surgical treatment resulting in progressive symptoms; and
2. High functioning status (i.e., ambulatory) with good rehabilitation potential; and
3. Life expectancy less than 3 years; and
4. Nutrition status with BMI greater than 16 kg/m2 or less than 35 kg/m2; and
5. Satisfactory psychosocial profile and support system is present

Special Considerations:

Special Considerations: The Plan will consider the following types of transplants for the circumstances and/or diagnoses listed below:

Single Lung Transplantation:

• Appropriate for all indications except as specified in Bilateral transplantation and Heart-Lung Transplant

Bilateral Lung Transplantation:

• Mandatory for generalized bronchiectasis
• Mandatory for end stage Cystic Fibrosis disease
• Suitable for other forms of respiratory failure not complicated by severe left ventricular cardiac dysfunction (see Heart-Lung indications)

Heart-Lung Transplantation:

• Eisenmenger syndrome with a surgically uncorrectable anomaly and irreversible pulmonary hypertension
• 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)

Living Lobar Lung Transplant:

• May be authorized in children or small adults only and generally only for cystic fibrosis.
• May be authorized in cases where it is clear a Member will not live long enough to receive a cadaveric transplant
• Will not be authorized in cases where the patient is in extremis (emergency situations)

Limitations

The Plan will not authorize the coverage of a lung transplant for Member meeting ONE of the following:

1. Active inhaled substance use (e.g., smoking cigarettes, smoking marijuana, inhaling e-cigarettes, vaping)
2. Active or uncontrolled alcohol use disorder or substance use disorder
3. Acute illness or clinically unstable
4. Active Hepatitis C disease
5. Any unresolved psychosocial concerns or history of noncompliance with and/or medical management
6. Acute coronary syndrome or myocardial infarction within 30 days (excluding demand ischemia)
7. Hepatitis B sAg+
8. Human immunodeficiency virus (HIV) infection unless ALL of the following are met:
   • CD4 count greater than 200 cells/mm3 for > 3 months prior to transplantation; and
   • Undetectable HIV-1 ribonucleic acid (RNA); and
   • Stable anti-retroviral therapy for > 3 months; and
   • Absence of serious complications associated with or secondary to HIV disease, (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections; Kaposi's sarcoma; or other neoplasm)
9. Malignancy with high risk of recurrence or death
10. Significant Coronary Artery Disease or Right or Left Ventricular Dysfunction Significant dysfunction of the liver,

Significant Coronary Artery Disease or Right or Left Ventricular Dysfunction, Significant dysfunction of the liver,

11. Stroke within 30 days or progressive cognitive impairment
12. Uncontrolled or untreatable infection, any source
13. Ventilator dependent and actively treated for acute respiratory failure (Chronic ventilator dependency is not a contraindication)
14. Other severe uncontrolled medical condition expected to limit survival after transplant

Codes