TRANS.00039 Portable Normothermic Organ Perfusion Systems

This policy addresses portable normothermic organ perfusion systems used to preserve and transport donor organs. Coverage is medically necessary only when used as part of the acquisition/collection/storage of a covered, medically necessary transplant and for donor organs initially deemed unacceptable due to limitations of static cold storage, and when organ-specific criteria are met—currently for lung perfusion (e.g., OCS Lung) in donor lung pairs with at least one high‑risk factor such as DCD, donor age >55, PaO2/FiO2 <300 mmHg, or prolonged ischemic time. Use that does not meet these criteria—including use with other solid organs or with standard-criteria organs acceptable for cold storage—is investigational and not medically necessary.

"Portable normothermic organ perfusion systems are consideredmedically necessarywhen the following criteria are met (both criteria set Aandcriteria set B):"