S2152, Solid organ(s), complete or segmental, single organ or combination of organs;
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
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
- Documentation demonstrating absence of chronic wasting or severe malnutrition
- Documentation confirming absence of active extrapulmonary or disseminated infection (culture/results/clinical notes).
Key Coverage Criteria
- 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)
- Irreversible primary pulmonary hypertension with severe heart failure.
- Nonspecific idiopathic severe pulmonary fibrosis.
- Eisenmenger syndrome with irreversible pulmonary hypertension and heart failure.
- Cystic fibrosis with severe heart failure.
- Chronic obstructive pulmonary disease with severe heart failure.
20 Active Policies
AMBETTER-CP.MP.132, Heart-Lung Transplant
AMBETTER-CP.MP.58, Intestinal and Multivisceral Transplant
AMBETTER-CP.MP.57, Lung Transplantation
AMBETTER-CP.MP.246, Pediatric Kidney Transplant
AMBETTER-CP.MP.120, Pediatric Liver Transplant
SUR703.006, Heart/Lung Transplant
SUR703.014, Isolated Small Bowel Transplant
SUR703.007, Kidney Transplant
SUR703.010, Lung and Lobar Lung Transplant
SUR703.009, Small Bowel/Liver and Multivisceral Transplant
BCBSIL-SUR703.006, Heart/Lung Transplant
BCBSIL-SUR703.014, Isolated Small Bowel Transplant
BCBSIL-SUR703.007, Kidney Transplant
BCBSIL-SUR703.008, Liver Transplant and Combined Liver-Kidney Transplant
BCBSIL-SUR703.010, Lung and Lobar Lung Transplant
BCBSIL-SUR703.009, Small Bowel/Liver and Multivisceral Transplant
BCBSMT-SUR703.006, Heart/Lung Transplant
BCBSMT-SUR703.014, Isolated Small Bowel Transplant
BCBSMT-SUR703.007, Kidney Transplant
BCBSMT-SUR703.008, Liver Transplant and Combined Liver-Kidney Transplant
Related Codes
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