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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-33000-23

Original Effective Date: 01/01/01

Reviewed: 05/22/14

Revised: 06/15/14

Subject: Heart Transplant

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

A heart transplant consists of replacing a diseased heart with a healthy donor heart. Transplantation is used for individuals with refractory end-stage cardiac disease.

Heart failure is the reduction of cardiac output and is considered severe when systemic circulation cannot meet the body’s needs under minimal exertion. Heart transplantation can potentially improve both survival and quality of life in those with end-stage heart failure.

Heart failure may be due to a number of differing etiologies, including ischemic heart disease, cardiomyopathy, or congenital heart defects. The leading indication for heart transplant has shifted over time from ischemic to nonischemic cardiomyopathy.

The demand for heart transplants far exceeds the availability of donor organs, and the wait time for those on the transplant waiting list has increased. The chronic shortage of donor hearts has led to the prioritization of those awaiting transplantation, to ensure greater access for individuals most likely to derive benefit. Prioritization criteria are issued by the United Network for Organ Sharing [UNOS]. Heart retransplantation raises ethical issues due to the lack of sufficient donor hearts for initial transplants. UNOS does not have separate organ allocation criteria for repeat heart transplant recipients.

POSITION STATEMENT:

 

Certificate of Medical Necessity

The transplant facility should submit a completed Certificate of Medical Necessity (CMN) along with a request for transplant services to expedite the medical review process.

1. Click this link Solid Organ Transplant - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Human heart transplantation meets the definition of medical necessity for adults and children with end-stage heart failure when selection criteria are met.

Adult transplantation

Accepted indications for cardiac transplantation:

  1. Hemodynamic compromise due to heart failure demonstrated by any of the following:
  1. Severe ischemia consistently limiting routine activity not amenable to bypass surgery or angioplasty, OR
  2. Recurrent symptomatic ventricular arrhythmias refractory to ALL accepted therapeutic modalities

Probable indications for cardiac transplantation

  1. Maximal Vo2 <14 mL/kg/min and major limitation of activities, OR
  2. Recurrent unstable ischemia not amenable to bypass surgery or angioplasty, OR
  3. Instability of fluid balance/renal function not due to patient noncompliance with regimen of weight monitoring, flexible use of diuretic drugs, and salt restriction

Pediatric transplantation

Accepted indications for cardiac transplantation:

  1. Heart failure with persistent symptoms at rest who require one or more of the following:
  1. Pediatric heart disease with symptoms of heart failure who do not meet the above criteria but who have:

Cardiac retransplantation after a failed primary cardiac transplant meets the definition of medical necessity in individuals who meet criteria for heart transplantation.

Cardiac transplantation is considered experimental or investigational in all other situations, as available clinical evidence does not support safety and effectiveness.

Potential contraindications to cardiac transplantation (subject to the judgment of the transplant center) include:

Transplant associated services which meet the definition of medical necessity include:

BILLING/CODING INFORMATION:

CPT Coding:

33940

Donor cardiectomy, including cold preservation.

33944

Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation.

33945

Heart transplant, with or without recipient cardiectomy

REIMBURSEMENT INFORMATION

None indicated.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date:National Coverage Determination (NCD) for Heart Transplants (260.9), located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Heart and Lung Transplant, 02-33000-24
Ventricular Assist Devices and Total Artificial Hearts, 02-33000-25

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8817. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011 Dec 13;58(25):e212-60.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-10049. 2013 ACCF/AHA guideline for the management of heart failure. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Am Coll Cardiol. 2013 Oct 15;62(16):e147-239.
  3. American Medical Association CPT (current edition).
  4. American Society of Transplantation (AST): Key Position Statements. Accessed 06/04/09.
  5. Blue Cross Blue Shield Association Medical Policy – Heart Transplant – 7.03.09 (November 2013).
  6. Blue Cross Blue Shield Association TEC Assessments 1988, p. 351 – Cardiac Transplants.
  7. Blue Cross Blue Shield Association TEC Assessments 1995 – Heart Transplant with High Risk Donor Hearts.
  8. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Heart Transplants, Publication 100-3, Section 260.9 (05/01/08).
  9. Costanzo MR, et al. (2010) The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. The Journal of Heart and Lung Transplantation, 29(8), 914-956.
  10. Deng MC, Ardehali A, Shemin R, Hickey A, MacLellan WR, Fonarow G. (2011) Relative roles of heart transplantation and long-term mechanical circulatory support in contemporary management of advanced heart failure—a critical appraisal 10 years after REMATCH. European Journal of Cardio-Thoracic Surgery, 40(4), 781-782.
  11. Gazit AZ, Canter CE. Impact of pulmonary vascular resistances in heart transplantation for congenital heart disease. Curr Cardiol Rev. 2011 May;7(2):59-66.
  12. InterQual® 2013.2. CP: Procedures; Transplantation, Cardiac.
  13. Kilic A, Weiss ES, George TJ, Arnaoutakis GJ, Yuh DD, Shah AS, Conte JV. (2012) What predicts long-term survival after heart transplantation? An analysis of 9,400 ten-year survivors. The Annals of thoracic surgery, 93(3), 699-704.
  14. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson L, Miller M, Young JB. (2012) Long-term mechanical circulatory support (destination therapy): on track to compete with heart transplantation? The Journal of thoracic and cardiovascular surgery, 144(3), 584-603.
  15. Mehra MR, et al. Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006. Accessed at http://www.ishlt.org/ on 04/28/14.
  16. Michielon G, Carotti A, Pongiglione G, Cogo P, Parisi F. Orthotopic heart transplantation in patients with univentricular physiology. Curr Cardiol Rev. 2011 May;7(2):85-91.
  17. Mora BN, Huddleston CB. Heart transplantation in biventricular congenital heart disease: indications, techniques, and outcomes. Curr Cardiol Rev. 2011 May;7(2):92-101.
  18. National Institute for Health and Clinical Excellence (NICE). Clinical Guideline (CG) 108. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care (August 2010). Accessed at http://www.nice.org.uk/ on 04/28/14.
  19. Organ Procurement and Transplantation Network Policies (04/10/14). Accessed at: http://optn.transplant.hrsa.gov/policiesAndBylaws/policies.asp on 04/28/14.
  20. Pietra BA, Kantor PF, Bartlett HL, Chin C, Canter CE, Larsen RL, Edens RE, Colan SD, Towbin JA, Lipshultz SE, Kirklin JK, Naftel DC, Hsu DT. Early predictors of survival to and after heart transplantation in children with dilated cardiomyopathy. Circulation. 2012 Aug 28;126(9):1079-86.
  21. St. Anthony’s ICD-9-CM Code Book (current edition).
  22. United Network of Organ Sharing (UNOS) Policy. Allocation of Thoracic Organs. Accessed 06/04/09.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/22/14.

GUIDELINE UPDATE INFORMATION:

01/01/01

Medical Coverage Guideline developed.

12/15/02

Reviewed and revised; statement was added regarding transplant facilities.

07/01/03

HCPCS coding update.

11/15/04

Scheduled review; added statement regarding organ transplants in HIV-positive recipients.

01/01/05

HCPCS coding update: added 33944, revised 33940 descriptor.

06/15/05

Revision to guideline, consisting of removal of investigational statement regarding HIV-positive recipients.

06/15/06

Scheduled review; no change in coverage statement.

06/15/07

Scheduled review (consensus); no change in coverage; reformatted guideline; updated references.

07/15/08

Scheduled review; no change in position statement. Update references.

07/15/09

Scheduled review; no change in position statement. Update description section with addition of status 7 listing from UNOS. Update reference section.

06/15/14

Scheduled review. Revised description, position statement, CPT coding and program exceptions. Updated references.

Date Printed: October 20, 2017: 08:41 AM