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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.

02-33000-24

Original Effective Date: 01/01/01

Reviewed: 05/22/14

Revised: 01/01/15

Subject: Heart and Lung 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:

Heart/lung transplantation involves a coordinated triple operative procedure consisting of procurement of a donor heart-lung block, excision of the heart and lungs of the recipient, and implantation of the heart and lungs into the recipient. A heart/lung transplantation refers to the transplantation of one or both lungs and heart from a single cadaver donor.

Combined heart/lung transplantation is intended to prolong survival and improve function in patients with end-stage cardiac and pulmonary diseases. The majority of recipients have Eisenmenger syndrome, followed by idiopathic pulmonary artery hypertension and cystic fibrosis. Eisenmenger syndrome is a form of congenital heart disease in which systemic-to-pulmonary shunting leads to pulmonary vascular resistance. Eventually, pulmonary hypertension may lead to a reversal of the intracardiac shunting and inadequate peripheral oxygenation, or cyanosis.

However, the total number of patients with Eisenmenger syndrome has been declining in recent years, as a result of corrective surgical techniques and improved medical management of pulmonary hypertension. Heart/lung transplants have not increased appreciably for other indications either, as it has become more common to transplant a single or double lung and maximize medical therapy for heart failure, rather than perform a combined transplant. In these, survival rates are similar to lung transplant rates. Bronchiolitis obliterans syndrome is a major complication; 1-, 5-, and 10-year survival rates are 68%, 50%, and 40%, respectively.

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.

When performed in an approved transplant facility, heart/lung transplants meet the definition of medical necessity for carefully selected individuals with end-stage cardiac and pulmonary disease specifically including, but not limited to, one of the following conditions:

Potential contraindications to heart/lung transplant (subject to the judgment of the transplant center) include:

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

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

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

BILLING/CODING INFORMATION:

CPT Coding:

33930

Donor cardiectomy-pneumonectomy, (including cold preservation)

33933

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

33935

Heart-lung transplant with recipient cardiectomy-pneumonectomy

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: Heart Transplants (260.9), located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Lung and Lobar Lung Transplant, 02-30000-10
Heart Transplant, 02-33000-23

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. BCBSF physician consultant review (10/22/00).
  6. Blue Cross Blue Shield Association Medical Policy – Heart/Lung Transplant – 7.03.08 (November 2013).
  7. Blue Cross Blue Association Medical Policy Reference Manual. 8.01.36. Extracorporeal Photopheresis after Solid-Organ Transplant and for Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma. February 2012.
  8. Blue Cross Blue Shield Association TEC Evaluations 1990 (p. 22).
  9. Center for Medicare & Medicaid Services. National Coverage Determination (NCD) for Extracorporeal Photopheresis (110.4). 04/02/07.
  10. Center for Medicare & Medicaid Services. National Coverage Determination (NCD) for Heart Transplants (260.9). 05/21/08.
  11. Christie JD, Edwards LB, Kucheryavaya AY et al. The Registry of the International Society for Heart and Lung Transplantation: twenty-seventh official adult lung and heart-lung transplant report--2010. J Heart Lung Transplant 2010; 29(10):1104-18.
  12. 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.
  13. Fadel E, et al. (2010). Long-term outcome of double-lung and heart–lung transplantation for pulmonary hypertension: a comparative retrospective study of 219 patients. European Journal of Cardio-Thoracic Surgery, 38(3), 277-284.
  14. Hartert M, et al. Lung Transplantation: a Treatment Option in End-Stage Lung Disease. Dtsch Arztebl Int. Feb 2014; 111(7): 107–116.
  15. Kotloff RM, Thabut G. (2012). Lung transplantation. American journal of respiratory and critical care medicine, 184(2).
  16. 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.
  17. National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance (IPG) 170: Living-donor lung transplantation for end-stage lung disease. Accessed at http://publications.nice.org.uk on 04/27/14.
  18. Orens JB, Estenne M, Arcasoy S et al. Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. International guidelines for the selection of lung transplant candidates: 2006 update – a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2006; 25(7):745-55.
  19. Organ Procurement and Transplantation Network Policies (04/10/14). Accessed at: http://optn.transplant.hrsa.gov/policiesAndBylaws/policies.asp on 04/26/14.
  20. St. Anthony’s ICD-9-CM Code Book (current edition). Allocation of Thoracic Organs. Updated 06/20/08.
  21. United Network of Organ Sharing (UNOS) Policy.
  22. U.S. Department of Health and Human Services “Institutional and Patient Criteria for Heart-Lung Transplantation” (1994) (accessed 11/06/02).

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.

11/15/04

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

01/01/05

Annual HCPCS coding update: added code 33933, revised code descriptor for 33930.

06/15/05

Revision of 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 statement; reformatted guideline; updated references.

07/15/08

Scheduled review; no change in position statement.

01/01/09

Annual HCPCS coding update: updated descriptor for code 33960.

07/15/09

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

10/15/10

Revision; related ICD-10 codes added.

01/01/12

Annual HCPCS coding update. Added 33961. Revised 33960 descriptor.

06/15/12

Revision; added Medicare Advantage program exception for extracorporeal photopheresis (ECP) following lung allograft transplantation. Updated references.

06/15/14

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

01/01/15

Annual CPT/HCPCS update. Deleted 33960, 33961.

Date Printed: October 20, 2017: 11:49 AM