Organ Transplant Policy Comparison
I.
Heart
2/9/2016
Full Coverage Details
BCBS
A. Benefit eligibility is considered for adult patients with
end-stage, irreversible, refractory, symptomatic heart
disease requiring maximal continuous medical and/or
mechanical support and who have:
1. a low functional status, and
2. a poor probability of survival, and
3. one of the following underlying conditions:
a. presence of an implanted ventricular assist device, or
b. refractory cardiogenic shock, or
c. dependency on intravenous inotropic support to
maintain adequate organ perfusion, or
d. maximal VO2 of 11-14 milliliters/kilogram/minute (or
55% of predicted) and major limitation of activities, or
e. severe ischemia (or recurrent unstable ischemia)
consistently limiting routine activity not amenable to
bypass surgery or percutaneous coronary intervention, or
f. recurrent symptomatic ventricular arrhythmias
refractory to all therapeutic modalities, or
g. ischemic cardiomyopathy not amenable to medical
therapy or revascularization procedures.
B. Benefit eligibility is considered for pediatric heart
transplantation in the following clinical situations:
1. Patients with heart failure with persistent symptoms at
rest who require one or more of the following:
a. continuous infusion of intravenous inotropic agents, or
b. mechanical ventilatory support, or
c. mechanical circulatory support.
2. Patients with pediatric heart disease with symptoms of
heart failure who do not meet the above criteria but who
have:
a. severe limitation of exercise and activity (if
measurable, such patients would have a peak maximum
oxygen consumption <50% predicted for age and sex), or
b. cardiomyopathies or previously repaired or palliated
congenital heart disease and significant growth failure
attributable to the heart disease, or
c. near sudden death and/or life-threatening arrhythmias
untreatable with medications or an implantable
defibrillator, or
d. restrictive cardiomyopathy with reactive pulmonary
hypertension, or
Medicaid
Each recipient’s condition is evaluated on an individual
basis. There may be other conditions that are indications
for coverage. The N.C. Medicaid program covers heart
transplantation for patients with end-stage heart disease
of any etiology who meet indications for transplantation
related to the following disease processes.
Adult
The following list is not all inclusive.
a. Symptomatic heart failure (NYHA Class III-IV)
refractory to medical therapy:
1. peak VO2 less than 11ml/kg/min (or % predicted peak
VO2 less than 45%)
2. peak VO2 = 12–16 ml/kg/min (or % predicted peak
VO2 = 45–60%) considered probable indication
b. Refractory life-threatening arrhythmias:
1. recurrent symptomatic life-threatening ventricular
arrhythmias, which cannot be controlled with all
available medical or surgical therapy
2. prolonged episodes of electromechanical
disassociation following AICD conversion of VT or
VF to sinus rhythm
c. Unstable angina with a high risk of myocardial
infarction in revascularization is not an option
d. Congenital anomalies not amenable to repair or
ventricular failure after prior palliative or
reconstructive procedures
Pediatric
The following list is not all inclusive.
a. Hypoplastic left heart syndrome, or other lethal
congenital heart disease for which there is no
standardized treatment
b. End-stage cardiomyopathy (including failed palliative
surgery)
Organ Transplant Policy Comparison
Heart
2/9/2016
e. reactive pulmonary hypertension and potential risk of
developing fixed, irreversible elevation of pulmonary
vascular resistance that could preclude orthotopic heart
transplantation in the future, or
f. anatomical and physiological conditions likely to
worsen the natural history of congenital heart disease in
infants with a functional single ventricle, or
g. anatomical and physiological conditions that may lead
to consideration for heart transplantation without
systemic ventricular dysfunction.
Retransplantation in patients with graft failure, due to
either technical reasons or hyperacute rejection is
considered medically necessary.
Retransplantation in patients with chronic rejection,
moderate graft vasculopathy or recurrent disease is
considered medically necessary when the patient
meets general patient section criteria as outlined
above.
II.
Not Covered
BCBS

A. Benefits for Human Heart Transplant are not available
when any of the following clinical conditions are
present:
1. Alcoholic cardiomyopathy (unless abstinent for at least
6 months),
2. Systemic illness that would limit life expectancy or
compromise recovery from cardiac transplantation,
3. Diabetes mellitus with evidence of significant endorgan complications, such as retinopathy, neuropathy,
nephropathy, and peripheral or cerebrovascular disease,
4. Severe peripheral vascular disease or cerebrovascular
disease,
5. Malignancy, life threatening, current or past (some
have suggested a five year window to establish "cure"),
6. Irreversible hepatic (liver) dysfunction (transaminases
twice normal, with associated coagulopathy),
irreversible renal (kidney) dysfunction (serum
creatinine greater than 2 mg/dl or clearance less than 50
cc/min),
9. Chronic bronchitis or chronic obstructive pulmonary
disease FEV 1 less than 60% predicted or any
irreversible lung disease,
10. Cachexia, even without major end-organ failure, as
survival is significantly less favorable,
11. Morbid obesity indicated by a BMI > 40, or a BMI >
35 with comorbid conditions,
12. Absence of documentation of nonsmoking status,
Medicaid
4.1 Adult
a. Advanced age (generally over 65)
b. Elevated and irreversible pulmonary vascular
resistance (>6 Woods units, and not responsive to
pharmacological manipulation)
c. History of malignancy (except certain malignancies
considered cured after >5 years)
d. Insulin-dependent diabetes, with evidence of organ
complications such as
1. Retinopathy
2. Neuropathy
3. Nephropathy
4. Peripheral and cerebrovascular disease
e. Severe peripheral vascular disease
f. HIV positive
g. Smoking/tobacco use—must be abstinent for
minimum of one year
h. Obesity greater than 130% of ideal body weight
i. Chronic bronchitis or chronic obstructive pulmonary
disease
j. Psychosocial history that would limit ability to
comply with medical care pre and post transplant
k. Irreversible hepatic function
Organ Transplant Policy Comparison
Heart
13. Recent substance abuse that will likely impair
compliance with post transplant protocols,
14. Psychosocial instability,
15. HIV positivity.
B. Pulmonary infarction or embolism during the
preceding eight weeks is considered a relative contraindication.
C. Heart transplants that require planned concurrent
coronary artery bypass graft surgery. This is considered
experimental
2/9/2016
l. Systemic illness/disease that would limit life
expectancy or compromise recovery from cardiac
transplantation
m. Current patient and/or caretaker non-compliance
that would make compliance with a disciplined
medical regime improbable
n. Heart transplants that require concurrent coronary
artery bypass graft surgery
o. History of or active substance abuse—must have
documentation of substance abuse program
completion plus six months of negative sequential
random drug screens
4.2 Pediatric
a. Unstable metabolic and hemodynamic status
despite receiving supportive measures
b. Active clinical infection
c. Significant neurological deficit
d. Significant renal malformations in infants under
one year
e. Chromosomal abnormalities or syndromes that
would limit survival or benefit from transplantation
f. History of or active substance abuse—must have
documentation of substance abuse program
completion plus six months of negative sequential
random drug screen
Note: To satisfy the requirement for sequential testing
as designated in this policy, DMA must receive a series
of test (alcohol and drug) results spanning a minimum
six-month period, allowing no fewer than a three-week
interval and no more than six-week interval between
each test during the given time period. A complete
clinical packet for prior approval must include at least
one documented test performed within one month of
the date of request to be considered.
g.
Psychosocial history that would limit ability to
comply with medical care pre and post transplant
h. Current patient and/or caretaker non-compliance
that would make compliance with a disciplined
medical regime improbable
Donors: Living donor expenses are not applicable for
a heart transplant.
Organ Transplant Policy Comparison
III.
Heart
2/9/2016
BCBS Policy Guidelines
Only those patients accepted for transplantation by a transplantation center and actively listed for
transplant should be considered for prior review. Guidelines should be followed for transplant
network or consortiums, if available.
IV.
None.
Medicaid Policy Guidelines