S1053
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Adult Clinical Indications*- Adults with end-stage, irreversible, refractory, symptomatic HF requiringmaximalcontinuous medical or mechanical support must have:
- A low functional status;and
- Heart transplantation is consideredmedically necessaryin carefully selected individuals when the following Adult or Pediatric Clinical Indications criteria (whichever is applicable)andthe General Individual Selection criteria below are met.
- A poor probability of survival;and
- ONEof the following underlying conditions:Supported by a mechanical circulatory support (MCS) device;orSupported by an intra-aortic balloon pump (IABP);orRefractory cardiogenic shock;orDependency onintravenous (IV) inotropic support to maintain adequate organ perfusion;orSevere ischemia consistently limiting routine activity not amenable to bypass surgery or percutaneous coronary intervention (PCI);orRecurrent unstable ischemia not amenable to bypass surgery or percutaneous coronary intervention [...]
- Supported by a mechanical circulatory support (MCS) device;or
1 Active Policy
ANTHEM-MP-A053845 — TRANS.00033 Heart Transplantation
Related Codes
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