Heart Transplantation

Aetna considers human heart transplantation medically necessary for indicated conditions (e.g., refractory heart failure, arrhythmias, cardiac re‑retransplantation, cardiomyopathies, congenital heart disease) when the member meets the transplanting institution’s protocol eligibility criteria or, if no protocol exists, the selection criteria. It is not medically necessary for patients with absolute contraindications such as irreversible end‑organ disease (unless a planned dual‑organ transplant), severe irreversible pulmonary hypertension/high PVR, recent intracranial stroke with persistent deficit, bleeding peptic ulcer, or hepatitis B antigen positivity.

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