TRANS.00033 Heart Transplantation

This policy addresses heart transplantation for end-stage heart failure. It is covered as medically necessary for carefully selected adults or children who meet both clinical and general selection criteria—typically including low functional status, poor survival prognosis despite maximal continuous medical or mechanical support, and one of the following: support with an MCS device or IABP, refractory cardiogenic shock, IV inotrope dependence, or ischemia not amenable to revascularization—without transplant contraindications per AST/ISHLT. It is not covered (investigational/not medically necessary) when these criteria are not met or when contraindications exist; relative contraindications include significant pulmonary hypertension (e.g., PASP ≥50 mmHg with TPG ≥15 mmHg or PVR ≥3 Wood units while SBP >85 mmHg).

"Heart transplantation is consideredmedically necessaryin carefully selected individuals when the following Adult or Pediatric Clinical Indications criteria (whichever is applicable)andthe General I..."