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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.

02-30000-10

Original Effective Date: 12/07/00

Reviewed: 06/26/14

Revised: 07/15/14

Subject: Lung and Lobar 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:

A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s). Transplantation is an option for individuals with end-stage lung disease.

End-stage lung disease may be the consequence of a number of different etiologies. The most common indications for lung transplantation are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. Prior to the consideration for transplant, individuals should be receiving maximal medical therapy, including oxygen supplementation, or surgical options, such as lung-volume reduction surgery for COPD. Lung or lobar lung transplantation is an option for those with end-stage lung disease despite these measures.

A lung transplant refers to single-lung or double-lung replacement. In a single-lung transplant, only one lung from a deceased donor is provided to the recipient. In a double-lung transplant, both the recipient's lungs are removed and replaced by the donor's lungs. In a lobar transplant, a lobe of the donor’s lung is excised, sized appropriately for the recipient’s thoracic dimensions, and transplanted. Donors for lobar transplant have primarily been living-related donors, with one lobe obtained from each of two donors (eg, mother and father) in cases for which bilateral transplantation is required. There are also cases of cadaver lobe transplants. Combined lung-pancreatic islet cell transplant is being studied for individuals with cystic fibrosis.

Since 2005, potential recipients have been ranked according to the Lung Allocation Score (LAS). Individuals 12 years of age and older receive a score between 1 and 100, based on predicted survival after transplantation and reduced by predicted survival on the waiting list. The LAS takes into consideration the recipient’s disease and clinical parameters. In 2010, a simple priority system was implemented for children younger than age 12 years. Under this system, children younger than 12 years with respiratory lung failure and/or pulmonary hypertension who meet criteria are considered “priority 1”, and all other candidates in the age group are considered “priority 2”.

POSITION STATEMENT:

REQUIRED: Certificate of Medical Necessity

NOTE: Submitting a completed Certificate of Medical Necessity with your request for (name of MCG) is required.

Click the link below to open the form. Complete all fields on the form thoroughly. Print and submit a copy of the form with your faxed request.

Lung transplantation meets the definition of medical necessity for selected individuals with irreversible, progressively disabling, end-stage pulmonary disease, including but not limited to the conditions listed below.

Lobar lung transplantation from a living or deceased donor meets the definition of medical necessity for selected individuals with end stage pulmonary disease, including but not limited to the conditions listed below.

Lung or lobar lung retransplantation meets the definition of medical necessity after a failed lung or lobar lung transplant in individuals who meet criteria for lung transplantation.

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

Potential contraindications to lung and lobar lung 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:

32850

Donor pneumonectomy (including cold preservation), from cadaver donor

32851

Lung transplant, single; without cardiopulmonary bypass

32852

Lung transplant, single; with cardiopulmonary bypass

32853

Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass

32854

Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass

32855

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral

32856

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral

HCPCS Coding:

S2060

Lobar lung transplantation

S2061

Donor lobectomy (lung) for transplantation, living donor

REIMBURSEMENT INFORMATION:

None

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Bronchiectasis: chronic dilatation of the bronchi marked by unpleasant breath and paroxysmal coughing with expectoration of mucopurulent matter.

Cystic fibrosis: a generalized autosomal recessive disorder, characterized by signs of chronic pulmonary disease due to excess mucous production in the respiratory tract in addition to other pathological abnormalities.

Dyspnea: difficult or labored breathing.

Emphysema: an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis end-stage pulmonary disease: irreversibility of severe anatomic changes in the lungs leading to incapacitating clinical manifestations and eventual respiratory failure.

Pneumonectomy: the excision of lung tissue, especially of an entire lung.

Pulmonary fibrosis: chronic inflammation and progressive fibrosis of the pulmonary alveolar walls with steadily increasing dyspnea, resulting in death from lack of oxygen or right heart failure.

RELATED GUIDELINES:

Heart and Lung Transplant, 02-33000-24

OTHER:

None applicable.

REFERENCES:

  1. Ahmad U, Wang Z, Bryant AS et al. Outcomes for lung transplantation for lung cancer in the United Network for Organ Sharing Registry. Ann Thorac Surg 2012; 94(3):935-40; discussion 40-1.
  2. AHRQ National Guideline Clearinghouse NGC-3738. Surgical treatments/interventions for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. ACCP evidence-based clinical practice guidelines. Chest. 2004 Jul;126(1 Suppl):63S-71S.
  3. AHRQ National Guideline Clearinghouse NGC-9774. Diagnosis and management of chronic obstructive pulmonary disease (COPD). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Mar.
  4. AHRQ National Guideline Clearinghouse NGC-9954. Idiopathic pulmonary fibrosis. The diagnosis and management of suspected idiopathic pulmonary fibrosis. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Jun.
  5. AHRQ National Guideline Clearinghouse NGC-10119. Interstitial lung disease. In: Pulmonary (acute & chronic). San Diego (CA): Work Loss Data Institute; 2009.
  6. Alexander BD, Petzold EW, Reller LB et al. Survival after lung transplantation of cystic fibrosis patients infected with Burkholderia cepacia complex. Am J Transplant 2008; 8(5):1025-30.
  7. American Medical Association CPT (current edition).
  8. American Society of Transplantation Key Position Statements. Accessed 06/04/09.
  9. Benden C, Edwards LB, Kucheryavaya AY et al. The registry of the International Society for Heart and Lung Transplantation: fifteenth pediatric lung and heart-lung transplantation report--2012. J Heart Lung Transplant 2012; 31(10):1087-95.
  10. Blue Cross Blue Shield Association Medical Policy – Lung and Lobar Lung Transplant – 7.03.07 (January 2014).
  11. 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.
  12. Blue Cross Blue Shield Association TEC Evaluations 1991 (p. 80).
  13. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Extracorporeal Photopheresis (110.4). 04/02/07.
  14. Centers for Medicare & Medicaid Services. Decision Memo for Transplant Centers: Re-Evaluation of Criteria for Medicare Approval (CAG-00061N). Accessed at cms.gov on 05/05/14.
  15. ECRI Institute Health Technology Forecast. Lung perfusion system preserved donor lungs for 11 hours before transplantation. October 27, 2013.
  16. National Institute for Health and Clinical Excellence (NICE). Interventional Procedure Guidance (IPG) 170. Living-donor lung transplantation for end-stage lung disease. (May 2006).
  17. National Institute for Health and Clinical Excellence (NICE). Clinical Guideline (CG) 63. Idiopathic pulmonary fibrosis: The diagnosis and management of suspected idiopathic pulmonary fibrosis. (June 2013).
  18. Medicare approved lung transplant centers. Accessed at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf on 05/01/14.
  19. Orens JB, Garrity Jr ER. General overview of lung transplantation and review of organ allocation. Proc Am Thorac Soc 2009; 6(1):13-9.
  20. 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. (Accessed 05/22/14).
  21. Organ Procurement and Transplantation Network (OPTN). Organ Distribution: Allocation of Thoracic Organs. Policy 3.7 Accessed at http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_9.pdf on 05/22/14.
  22. Pinney ME, Rosenberg AF, Hampp C et al. Invasive fungal infections in lung transplant recipients not receiving routine systemic antifungal prophylaxis: 12-year experience at a university lung transplant center. Pharmacotherapy 2011; 31(6):537-45.
  23. Sherman W, Rabkin DG, Ross D et al. Lung transplantation and coronary artery disease. Ann Thorac Surg 2011; 92(1):303-8.
  24. St. Anthony’s ICD-9-CM Code Book (current edition).
  25. Thabut G, Christie JD, Kremers WK et al. Survival differences following lung transplantation among US transplant centers. Jama 2010; 304(1):53-60.
  26. United Network of Organ Sharing (UNOS) Policy. Allocation of Thoracic Organs. Updated 06/20/08. Accessed 06/04/09.
  27. United Network for Organ Sharing (UNOS). Questions and answers for professionals about lung allocation policy. Accessed at http://www.unos.org/docs/Lung_Professional.pdf. On 05/22/14..
  28. Yusen RD, Shearon TH, Qian Y et al. Lung transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1047-68.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/26/14.

GUIDELINE UPDATE INFORMATION:

12/07/00

New Medical Coverage Guideline

09/01/01

HCPCS coding changes.

12/15/02

Reviewed and revised; statement was added regarding transplant facilities.

11/15/04

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

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); 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 references.

10/15/10

Revision; related ICD-10 codes added.

10/01/11

Revision; deleted ICD9 code 516.3; added ICD9 code 516.69.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

06/15/12

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

07/15/14

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

Date Printed: August 21, 2017: 07:53 PM