Lung Transplantation

Aetna covers lung transplantation as medically necessary for patients who meet the transplanting institution's selection criteria with end‑stage lung disease from listed conditions (e.g., cystic fibrosis, emphysema/alpha‑1, pulmonary fibrosis, Eisenmenger's, LAM, bronchiectasis, primary pulmonary hypertension) provided disease‑specific criteria are met (e.g., CF—≥2 listed signs of clinical deterioration; emphysema—hypercapnic hospitalizations plus BODE ≥7; pulmonary fibrosis—DLCO <60% or cor pulmonale/TLC <70%; Eisenmenger's—NYHA III, pulmonary hypertension or RV failure). It is not medically necessary for persons with active lung malignancy (or other cancers not in remission), multi‑system disease not primarily confined to the lung, significant GI disease, refractory uncontrolled hypertension, or when other effective treatments/surgical options exist, and diabetics require careful evaluation.

"Disease-specific: Lung transplant for pulmonary hypertension is considered medically necessary for persons who meet the general criteria for lung transplantation plus any of the following criteria,..."