32854
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
87.75
Facility
$4494.76
Non-Facility
$4494.76
Documentation Required
- When evaluating candidates with prior non-pulmonary malignancy: documentation that cancer is in remission per policy requirements.
- Selection criteria must be met for CPT and HCPCS codes listed (explicit selection criteria referenced but not included in this chunk).
- Spirometry and pulmonary function testing for BOS/CLAD staging and for pre- and post-intervention monitoring.
- For consideration of LTX after HSCT or for refractory BO: documentation of prior treatments and failure of conventional therapies (e.g., "Evaluation for LTX was initiated after failure of a median of 4 immunosuppressive regimens").
Key Coverage Criteria
- Disease-specific: Lung transplant for pulmonary hypertension is considered medically necessary for persons who meet the general criteria for lung transplantation plus any of the following criteria, and valvular disease has been excluded by echocardiography: Persons who are NYHA III, failing conventional vasodilators (calcium channel blockers or endothelin receptor antagonists); Persons who are NYHA III, and have initiated or being considered for initiation of parenteral or subcutaneous vasodilat [...]
- Disease-specific: Lung transplant for sarcoidosis is considered medically necessary for persons who meet the general criteria for lung transplantation plus any of the following disease-specific criteria: DLCO <60% predicted; Presence of cor pulmonale or pulmonary hypertension; Total lung capacity <70% predicted.
- Aetna considers lung transplantation medically necessary for any of the following qualifying conditions for members who meet the transplanting institution's selection criteria: Alpha1-antitrypsin deficiency; Bronchopulmonary dysplasia; Congenital heart disease (Eisenmenger's defect or complex); Cystic fibrosis; Graft-versus-host disease or failed primary lung graft; Lymphangioleiomyomatosis (LAM) with end-stage pulmonary disease; Obstructive lung disease (e.g., bronchiectasis, bronchiolitis obli [...]
- Disease-specific: Lung transplant for cystic fibrosis (CF) is considered medically necessary for persons who meet the general selection criteria for lung transplantation and exhibit at least 2 of the following signs and symptoms of clinical deterioration: Cycling intravenous antibiotic therapy; Decreasing forced expiratory volume in 1 second (FEV1); Development of carbon dioxide (CO2) retention (pCO2 greater than 50 mm Hg); FEV1 less than 30% predicted; Increasing frequency of hospital admission [...]
- Disease-specific: Lung transplant for emphysema (including alpha 1-antitrypsin deficiency) is considered medically necessary for persons who meet the general selection criteria for lung transplantation and both of the following clinical criteria: Hospitalizations for exacerbation of COPD associated with hypercapnia in the preceding year (Hypercapnia defined as pCO2 greater than or equal to 50 mm Hg with hospitalizations and/or associated factors: Declining body mass index; Increasing oxygen requ [...]
- Disease-specific: Lung transplant for Eisenmenger's complex is considered medically necessary for persons who meet the general criteria for lung transplantation and any of the following disease-specific criteria: Marked deterioration in functional capacity (NYHA Class III); Pulmonary hypertension with mean pulmonary artery pressure by right heart catheterization >25 mm Hg at rest or 30 mm Hg with exercise; Signs of right ventricular failure – progressive hepatomegaly, ascites.
8 Active Policies
AMBETTER-CP.MP.57 — Lung Transplantation
AETNA-CPB-0598 — Lung Transplantation
ANTHEM-MP-A053821 — TRANS.00009 Lung and Lobar Transplantation
BCBSIL-SUR703.010 — Lung and Lobar Lung Transplant
BCBSMT-SUR703.010 — Lung and Lobar Lung Transplant
Related Codes
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