Organ Transplant Policy Comparison
I.
Heart & Lung
2/9/2016
Differences in Coverage
No differences in specified covered conditions
II.
Coverage Exclusion
BCBS
Medicaid
1.1
General Criteria
Procedures, products, and services related to this policy
are not covered when
a. the recipient does not meet the eligibility requirements
listed in Section 2.0;
b. the recipient does not meet the medical necessity criteria
listed in Section 3.0;
c. the procedure, product, or service unnecessarily
duplicates another provider’s procedure, product, or
service; or
d. the procedure, product, or service is experimental or
investigational.
1.2
Specific Criteria
a.
Coverage is not provided for organs sold rather
than donated to the recipient.
b.
Contra-indications for heart/lung transplants
include the following conditions:
Emotional problems or recent substance abuse that
will likely impair compliance with post transplant
protocols;
History of non-compliance with medical management;
Lack of social support that will likely impair
compliance with post transplant protocols;
Uncured malignancy (except when transplant is done
for a cure);
Other major organ system disease or infection
including major vascular disease;
Morbid obesity indicated by a BMI > 40, or a BMI >
35 with comorbid conditions;
HIV positivity;
Absence of documentation of nonsmoking status.
1.
Emotional problems or recent substance abuse
that will likely impair compliance with post transplant
protocols;
2.
History of non-compliance with medical
management;
3.
Lack of social support that will likely impair
compliance with post transplant protocols;
4.
Uncured malignancy (except when transplant is
done for a cure);
5.
Other major organ system disease or infection
including major vascular disease;
6.
Morbid obesity indicated by a BMI > 40, or a BMI
> 35 with comorbid conditions;
7.
HIV positivity; or
8.
Absence of documentation of nonsmoking
status.
Organ Transplant Policy Comparison
III.
Heart & Lung
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 applicable.
IV.
Medicaid Policy Guidelines
None.