Heart-Lung Transplant

This policy covers heart‑lung transplantation for adults (≥18 years) with concurrent end‑stage heart and lung disease, including irreversible primary pulmonary hypertension with severe heart failure, end‑stage pulmonary fibrosis, cystic fibrosis, severe COPD/emphysema with heart failure, Eisenmenger syndrome, and select complex congenital heart disease such as Fontan physiology. Coverage requires meeting specified disease‑severity and age staging criteria and excludes candidates with active contraindications (for example untreated/detectable HIV, active malignancy or disseminated infection including TB, severe malnutrition, inability to adhere to post‑transplant care), short non‑cardiopulmonary life expectancy, GFR <30 mL/min/1.73 m2 unless multi‑organ transplant is considered, recent acute organ failure, or retransplantation requested <6 months after the primary transplant.

"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)"