Pediatric Heart Transplant

This policy covers pediatric (<18 years) heart transplantation and re‑transplantation for end‑stage heart disease when medical‑necessity criteria are met, including indications such as Stage D or severe Stage C heart failure (e.g., peak VO2 <50% predicted), cardiomyopathies, previously repaired/palliated congenital heart disease, single‑ventricle infant physiology, pulmonary hypertension at risk for fixed PVR, and cardiac graft vasculopathy. Major requirements/limitations: applies only to pediatric members, reversible causes of heart failure must be excluded and expected non‑cardiopulmonary life expectancy ≥2 years; contraindications include GFR <30 mL/min/1.73 m² (unless multi‑organ), uncontrolled/active high‑risk malignancy or infection, severe fixed pulmonary vascular resistance, untreated HIV with detectable viral load absent documentation, retransplantation during acute rejection or within 6 months, and inadequate adherence or social/support systems.