33945
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
87.26
Facility
$4516.80
Non-Facility
$4516.80
Documentation Required
- Oncology records showing absence of active malignancy or documentation of complete resection / assessment of low likelihood of recurrence and acceptable risk.
- Functional status and rehabilitation records; documentation of ventilatory status and whether ambulatory ECMO is being used as a bridge-to-transplant.
- Laboratory results: serum bilirubin (< 2.5 mg/dL) and measured or estimated creatinine clearance (> 50 ml/min/kg).
- Life expectancy assessment documenting > 2 years expected survival absent cardiopulmonary disease.
Key Coverage Criteria
- Heart-lung transplantation is medically necessary for persons with severe refractory heart failure plus either end-stage lung disease or irreversible pulmonary hypertension when the selection criteria are met and no absolute contraindications are present.
- Severe (New York Heart Association (NYHA) classification III or IV) heart failure where right ventricular function would not be restored with lung transplant alone.
- Chronic obstructive pulmonary disease with severe heart failure.
- Congenital heart disease associated with pulmonary hypertension that are not amenable to lung transplantation and repair by standard cardiac surgery.
- Cystic fibrosis with severe heart failure.
- Eisenmenger's complex with irreversible pulmonary hypertension and severe heart failure.
3 Active Policies
AMBETTER-CP.MP.138 — Pediatric Heart Transplant
AETNA-CPB-0597 — Heart-Lung Transplantation
ANTHEM-MP-A053845 — TRANS.00033 Heart Transplantation
Related Codes
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