Effective Date: 02/02/2011
Title: Lung Transplantation
Revision Date: 10/01/2015
CPT Code(s): 32850-32856
will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
maintains a national network of Centers of Excellence for members who require
Transplants and transplant related services are covered only when performed at a
transplant center previously approved by QualChoice.
Progressive lung disease
that severely limits daily quality of life despite
optimal medical and other surgical therapy is known as end-stage lung
End-stage lung disease is
frequently treated with lung transplantation. Lung transplantation is a
treatment option used for end-stage lung disease when certain criteria are
Lung transplantation and related
services require preauthorization.
Lung Transplant services may be
confined to the QualChoice transplant network.
Note: All transplants must
be approved by the Medical Director prior to authorization.
1. QualChoice considers lung
transplantation medically necessary for any of the following qualifying
conditions for members who meet the transplanting institution`s selection
criteria. In the absence of an institution`s selection criteria, members must
meet both the general selection criteria (see section on General Selection
Criteria) and any applicable disease-specific selection criteria (see
Disease-Specific Selection Criteria accompanying the list of Qualifying
Qualifying Conditions for Lung Transplantation (Not an All-Inclusive List)
A. Alpha1-antitrypsin deficiency (E88.01): Persons who meet the
emphysema/alpha1-antitrypsin deficiency disease-specific selection criteria
B. Bronchopulmonary Dysplasia (P27.1)
C. Congenital Heart Disease (Eisenmenger`s Defect or Complex) (Q21.8): Persons
who meet the disease-specific criteria for Eisenmenger`s below
D. Cystic Fibrosis (E84.0 – E84.9): Persons who meet the disease-specific
selection criteria for cystic fibrosis
E. Graft-Versus-Host Disease (D89.810 – D89.813) or failed Primary Lung Graft.
F. Obstructive Lung Disease (e.g., emphysema, chronic obstructive pulmonary
disease, bronchiolitis obliterans, bronchiectasis) (J41.8, J43.0 – J43.2, J43.8
- J43.9, J44.0 – J44.1, J44.9, J47.0 – J47.1, J47.9): Persons with pulmonary
fibrosis, see the disease-specific selection criteria for pulmonary fibrosis
G. Primary Pulmonary Hypertension (I27.0): Persons who meet the disease-specific
selection criteria for primary pulmonary hypertension
H. Restrictive Lung Disease (e.g., idiopathic pulmonary fibrosis, desquamative
interstitial fibrosis, post-chemotherapy, allergic alveolitis, systemic
sclerosis [scleroderma], collagen vascular disease, asbestosis, eosinophilic
granuloma, and sarcoidosis) (C96.5 – C96.6, D86.0, D86.2, J61, J67.0 – J67.9,
J84.112, J84.117, J98.4, M34.0 – M34.9, M35.9, M36.8): Persons with sarcoidosis,
see the disease-specific selection criteria below
I. Lymphangioleiomyomatosis (LAM) (J84.81) with End-Stage Pulmonary Disease
General Selection Criteria:
The member must meet the transplanting institution`s selection criteria. In the
absence of an institution`s selection criteria, all of the following selection
criteria must be met, and none of the contraindications listed below should be
A. Adequate liver and kidney function, defined as a bilirubin of less than 2.5
mg/dl and a creatinine clearance of greater than 50 ml/min/kg; and
B. Adequate cardiac status (e.g., no angiographic evidence of significant
coronary artery disease, ejection fraction greater than 40%, no myocardial
infarction in last 6 months, negative stress test). Persons with any cardiac
symptoms may require heart catheterization to rule out significant heart
C. Adequate functional status. Under established guidelines, active
rehabilitation is considered important to the success of transplantation.
Mechanically-ventilated or otherwise immobile persons are considered poor
candidates for transplantation; and
D. Absence of acute or chronic active infection (pulmonary or non-pulmonary)
that is not adequately treated; and
E. Limited life expectancy of less than 2 years; and
F. No uncontrolled and/or untreated psychiatric disorders that interfere with
compliance to a strict treatment regimen; and
G. No active alcohol or chemical dependency that interferes with compliance to a
strict treatment regimen. Persons with a history of drug or alcohol abuse must
be abstinent for at least 3 months before being considered an eligible
transplant candidate; and
H. Absence of inadequately controlled HIV/AIDS infection, defined as:
a. CD4 count greater than 200 cells/mm3 for greater than 6 months; and
b. HIV-1 RNA (viral load) undetectable; and
c. On stable antiviral therapy greater than 3 months; and
d. No other complications from AIDS, such as opportunistic infection (e.g.,
aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections) or
neoplasms (e.g., Kaposi`s sarcoma, non-Hodgkin`s lymphoma).
Contraindications: Lung transplantation is considered experimental and
investigational for persons with the following contraindications to lung
transplant surgery as the safety and effectiveness of lung transplantation in
persons with these contraindications has not been established:
A. Multi-system disease. Persons with potentially multi-system diseases such as
systemic sclerosis (scleroderma), other collagen vascular diseases such as
systemic lupus erythematosus, or sarcoidosis must be carefully evaluated to
ensure that their disease is primarily confined to the lung. Persons with
diabetes must be carefully evaluated to rule our significant diabetic
complications such as nephropathy, neuropathy or retinopathy.
B. Smoking. Persons with a history of smoking must be abstinent for 6 months
before being considered eligible for lung transplantation.
C. Malignancy involving the lung (primary or metastatic). Persons with a history
of non-pulmonary cancer must be in remission before being considered a lung
transplant candidate. Note: Because of disappointing results, lung
transplantation is considered experimental and investigational as a treatment
for bronchioloalveolar carcinoma.
D. Presence of gastrointestinal disease (e.g., bleeding peptic ulcer,
diverticulitis, chronic hepatitis).
E. Refractory uncontrolled hypertension.
F. Other effective medical treatments or surgical options are available.
G. Single-lung transplantation is contraindicated in persons with chronic
pulmonary infections (e.g., bronchiectasis, chronic bronchitis, and cystic
2. QualChoice considers lobar (from living-related donors or cadaver donors)
lung transplantation medically necessary for persons with end-stage pulmonary
disease when selection criteria are met (see above).
3. QualChoice considers lung xenotransplantation (e.g., porcine xenografts)
experimental and investigational for any pulmonary conditions.
Disease-Specific Selection Criteria:
A. Lung transplant for cystic fibrosis is considered medically necessary for
persons who meet the general selection criteria for lung transplantation and
exhibit at least two of the following signs and symptoms of clinical
1. Initiation of supplemental enteral feeding by percutaneous endoscopic
gastrostomy or parenteral nutrition.
2. Cycling intravenous antibiotic therapy.
3. Non-invasive nocturnal mechanical ventilation.
4. Increasing frequency of hospital admission.
5. Increasing severe exacerbation of cystic fibrosis - especially an episode
requiring hospital admission.
6. Recurrent massive hemoptysis.
7. Development of CO2 retention (pCO2 greater than 50 mm Hg).
8. Worsening arterial-alveolar (A-a) gradient requiring increasing
concentrations of inspired oxygen (FiO2).
9. Decreasing FEV1.
10. FEV1 less than 30% predicted.
B. Lung transplant for emphysema (including alpha 1-antitrypsin deficiency) is
considered medically necessary for persons who meet the general criteria for
lung transplantation and both of the following clinical criteria:
1. Hospitalizations for exacerbation of chronic obstructive pulmonary disease
associated with hypercapnia in the preceding year. Hypercapnia is defined as
pCO2 greater than or equal to 50 mm Hg with hospitalizations and/or the
following associated factors:
a. reduced serum albumin
b. declining body mass index
c. increasing oxygen requirements
d. presence of cor pulmonale (defined as clinical diagnosis by a physician or
any 2 of the following:
i. right ventricular hypertrophy or right atrial enlargement on EKG
ii. enlarged pulmonary arteries on chest X-ray
iii. pedal edema or jugular venous distention
iv. mean pulmonary artery pressure by right heart catheterization of greater
than 25 mm Hg at rest or 30 mm Hg with exercise
2. FEV1 less than 30% predicted.
C. Lung transplant for Eisenmenger`s Complex is considered medically necessary
for persons who meet the general criteria for lung transplantation and any of
the following disease-specific criteria:
1. Signs of right ventricular failure -- progressive hepatomegaly, ascites.
2. Marked deterioration in functional capacity (New York Heart Association
(NYHA) Class III).
3. Pulmonary hypertension with mean pulmonary artery pressure by right heart
catheterization greater than 25 mm Hg at rest or 30 mm Hg with exercise.
D. Lung transplant for pulmonary fibrosis is considered medically necessary for
persons who meet the general criteria for lung transplantation and any of the
following disease-specific criteria:
1. Presence of cor pulmonale (indicative of severe pulmonary fibrosis) or
2. Diffusing capacity for carbon monoxide (DLCO) less than 39%.
3. A 10% or greater decrement in the FVC during 6 months of follow up.
4. A decrease in pulse oximetry below 88% during a 6-minute walk test (6-MWT).
E. Lung transplant for pulmonary hypertension is considered medically necessary
for persons who meet the general criteria for lung transplantation plus any of
the following criteria:
1. Persons who are New York Heart Association (NYHA) III, failing conventional
vasodilators (calcium channel blockers or endothelin receptor antagonists).
2. Persons who are New York Heart Association (NYHA) III, and have initiated or
being considered for initiation of parenteral or subcutaneous vasodilator
Refer to the Prognostic Factors for PH in the ISHLT consensus report. Note: NYHA
Class III for heart failure is defined as follows:
Persons with cardiac disease resulting in marked limitation of physical
activity. They are comfortable at rest. Less than ordinary activity (i.e., mild
exertion) causes fatigue, palpitation, dyspnea, or anginal pain.
F. Lung transplant for sarcoidosis is considered medically necessary for persons
who meet the general criteria for lung transplantation plus any of the following
1. Presence of cor pulmonale (indicative of severe pulmonary fibrosis) or
2. Total lung capacity less than 70% predicted.
3. Diffusion capacity (DLCO) less than 60% predicted.
Codes Used In This BI:
32850 Donor pneumonectomy(s) (incl. cold preservation), from cadaver donor
32851 Lung transplant, single; w/out cardiopulmonary bypass
32852 Lung transplant, single; w/ cardiopulmonary bypass
32853 Lung transplant, double (bilateral sequential or en bloc); w/out
32854 Lung transplant, double (bilateral sequential or en bloc);
32855 Backbench standard preparation of cadaver donor lung allograft prior to
transplantation, incl. 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, incl. dissection of allograft from surrounding soft tissues to
prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral
transplantation has become a viable treatment option for carefully selected
patients with end-stage pulmonary disease (ESPD). Single, double, and lobar-lung
transplantation have all been performed successfully for a variety of diseases.
Single-lung transplantation appears to be most effective for patients with
end-stage pulmonary fibrosis, while double-lung transplantation is most
effective for patients with end-stage chronic obstructive pulmonary disease and
cystic fibrosis in whom cardiac function has been preserved. Lobar-lung
transplantation (from living donors or cadaver donors) is usually reserved for
children or adolescents who are appropriate candidates for lung transplantation
and will not survive waiting for cadaver lungs. Indications for lung
transplantation in pediatric patients include pulmonary vascular disease,
bronchiolitis obliterans, bronchopulmonary dysplasia, graft failure due to viral
pneumonitis, and cystic fibrosis.
obstructive pulmonary disease and alpha 1-antitrypsin deficiency, the two
principal causes of emphysema, are responsible for approximately 60 % of all
single-lung transplantations performed. Other indications for single-lung
transplantation include primary pulmonary hypertension, Eisenmenger`s syndrome,
as well as a variety of interstitial lung diseases (e.g., interstitial pulmonary
fibrosis, emphysema, and alpha 1-antitrypsin deficiency are the most common
indications for double-lung transplantation, also known as bilateral single-lung
transplantations (sequential replacement of both lungs). Comparing patients who
have undergone en bloc double-lung transplantation to patients who have
undergone bilateral single-lung transplantations, studies have shown a better
outcome for those who have undergone the bilateral sequential procedure. The
latter is generally considered the procedure of choice for patients with any
pulmonary disorder complicated by chronic airway infection, such as
bronchiectasis, cystic fibrosis, and chronic bronchitis. The possibility of
spillover of infection from the native lung to the allograft precludes
single-lung transplantation in such patients.
lung transplantation offers acceptable prospects for 5-year survival, chronic
rejection and donor shortage remain to be major problems. To address the problem
of donor shortage, living-donor lobar-lung transplantation has been performed
with satisfactory intermediate survival and functional results. In lobar-lung
transplantation, a lobe of the donor`s lung is excised, sized appropriately for
the recipient, and transplanted. Common indications for living-donor bilateral
lobar-lung transplantation are cystic fibrosis and severe primary pulmonary
hypertension. Based on available scientific evidence, there is no significant
difference in effectiveness between living-donor lobar-lung transplantation and
cadaver lobar-lung transplantation.
currently two surgical therapies for the treatment of end-stage emphysema: lung
transplantation and lung volume reduction surgery (LVRS) (see CPB 160 - Lung
Volume Reduction Surgery). Ideal candidates for LVRS are those with
hyperinflation, heterogeneous distribution of disease, FEV1 of more than 20 %,
and normal PCO2. Patients with diffuse disease, low FEV1, hypercapnia, and
associated pulmonary hypertension are directed toward transplantation. Moreover,
lung transplantation provides more satisfactory results than LVRS for patients
with emphysema due to alpha1-antitrypsin deficiency. Combinations of lung
transplantation and LVRS, simultaneously or sequentially, are feasible but
Complications of lung transplantation include re-implantation response and
airway complications. Rejection may occur in the hyper acute, acute, or chronic
settings and requires judicious management with immunosuppression. Infection and
malignancy remain potential complications of the commitment to lifelong systemic
immunosuppression. Obese (> 20% of ideal body weight), cachectic (< 80% of ideal
body weight), mechanically ventilated or otherwise immobile patients are
considered poor candidates for transplantation.
There is a
steadily increasing need for a greater supply of lung donors.
Xenotransplantation offers the possibility of an unlimited supply of lungs that
could be readily available when needed. However, antibody-mediated mechanisms
cause the rejection of pig organs transplanted into non-human primates, and
these mechanisms provide key immunological barriers that have yet to be
overcome. Although porcine hearts have functioned in heterotopic sites in
non-human primates for periods of several weeks, no transplanted porcine lung
has functioned for even 24 hours. Currently, lung xenotransplantation is not a
clinically applicable option, and is therefore considered an experimental and
colleagues (2008) noted that lung transplantation impairs surfactant activity,
which may contribute to primary graft dysfunction (PGD). In an open, randomized,
controlled prospective study, these researchers examined if the administration
of surfactant during transplantation serves as an effective preventive measure.
A total of 42 patients scheduled for single (n = 38) or double (n = 4) lung
transplantation were randomly assigned to receive, or not, intra-operative
surfactant treatment. In the treated group, bovine surfactant was administered
at a dose of 20 mg phospholipids/kg body weight through bronchoscope after the
establishment of bronchial anastomosis. The groups were compared for oxygenation
(PaO2/FiO2), chest X-ray findings, PGD grade, and outcome. Compared with the
untreated group, patients who received surfactant were characterized by better
post-operative oxygenation mean PaO2/FiO2 (418.8 +/- 123.8 versus 277.9 +/- 165
mm Hg, p = 0.004), better chest radiograph score, a lower PGD grade (0.66 versus
1.86, p = 0.005), fewer cases of severe PGD (1 patient versus 12, p < 0.05),
earlier extubation (by 2.2 hrs.; 95 % CI 1.1 to 4.3 hrs., p = 0.027), shorter
intensive care unit stay (by 2.3 days; 95 % CI 1.47 to 3.74 days, p = 0.001),
and better vital capacity at 1 month (61 % versus 50 %, p = 0.022). One treated
and 2 untreated patients died during the first post-operative month. The authors
concluded that surfactant instillation during lung transplantation improves
oxygenation, prevents PGD, shortens intubation time, and enhances early
post-transplantation recovery. Moreover, they stated that further, larger
studies are needed to evaluate if surfactant should be used routinely in lung
Orens, Jonathan et al. Guidelines
for Selection of Lung Transplant Candidates;
The Journal of Heart and Lung Transplantation, vol 25 issue
Steinman TI, Becker BN, Frost AE,
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Gross TJ, Hunninghake GW.
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Meyers BF, Patterson GA. Lung
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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.