33935
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
89.49
Facility
$4605.98
Non-Facility
$4605.98
Documentation Required
- Clinical documentation of NYHA class (for ≥18 years) or AHA stage (for <18 years)
- Documentation/clinical evidence estimating life expectancy in the absence of cardiopulmonary disease (≥2 years)
- For HIV‑positive candidates: documentation of CD4 count >200 cells/mm³ for at least 3 months prior to transplantation to be considered for exception to contraindication
- Documentation of current/effective antiretroviral therapy (ART) if member is HIV-positive
Key Coverage Criteria
- Heart/lung transplantation is consideredmedically necessarywhen the following clinical indicationsandthe general individual selection criteria listed below are met.
- Clinical Indications -Individuals must meetoneof the following criteria:
- Irreversible primary pulmonary hypertension with heart failure;or
- Secondary pulmonary hypertension and resulting heart failure due to pulmonary fibrosis, cystic fibrosis, chronic obstructive pulmonary disease or emphysema;or
- Eisenmenger's complex or other types of congenital heart disease with irreversible pulmonary hypertension and heart failure.
- Age ≥ 18 years with both end-stage heart disease and end-stage lung disease (heart-lung transplantation is medically necessary when both conditions are present)
8 Active Policies
AMBETTER-CP.MP.132 — Heart-Lung Transplant
ANTHEM-MP-A053840 — Status
BCBSIL-SUR703.006 — Heart/Lung Transplant
BCBSMT-SUR703.006 — Heart/Lung Transplant
BCBSNM-SUR703.006 — Heart/Lung Transplant
Related Codes
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