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HealthPartners

Coverage criteria policies

Transplants

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

HealthPartners Centers of Excellence
Many plans require that transplant procedures be performed at HealthPartners Transplant Centers of Excellence (COE). Some plans allow for use of non-Center of Excellence transplant facilities. Check your plan documents or contact Member Services to determine what facilities are available to you and how your choice will affect your coverage.

Please note: Cornea transplants are outside the scope of this policy. They are covered without prior notification or authorization. Cornea transplants may be received from providers outside the HealthPartners Transplant COEs.

Prior Notification/Authorization Process
  1. Prior to selecting a transplant provider submission of a transplant pre-consultation prior authorization form from the referring physician is required. This prior authorization will support the initiation of care and benefit coordination.
  2. Prior notification or prior authorization is required before the actual visit date for pre-transplant evaluation as outlined below.
  3. Prior notification or prior authorization is required at the time of pre-transplant listing or start of treatment for deemed transplant candidate as outlined below.

For more information, please see the related content at right for the HealthPartners Transplant Resources and COE Networks and for the transplant prior notification and authorization process and form.

Prior notification is required for the following situations

Prior notification is required at the time of pre-transplant evaluation and at the time of pre-transplant listing when performed at a HealthPartners Transplant Center of Excellence (COE) for the following transplants:

  1. Kidney
  2. Heart
  3. Liver
  4. Lung
  5. Simultaneous pancreas kidney (SPK) and pancreas after kidney (PAK)
  6. Stem cell, blood and bone marrow transplants for diagnoses listed below under Indications that are Covered, #8 and #9.
Prior authorization is required for the following situations

Prior authorization is required at the time of pre-transplant evaluation and at the time of pre-transplant listing for all of the following transplants:

  1. New techniques for transplants listed above as only requiring prior notification.
  2. Any transplant at non-designated COEs (Out of Network, need for transfer, etc.)
  3. Any transplant for a diagnosis that is not listed below under Indications that are Covered section, #1 through #9.
  4. Pancreas transplant alone (PTA)
  5. Small bowel transplant
  6. Multiple organ transplants
Does Not Require Prior Authorization or Prior Notification for consultation, evaluation or listing
  1. Donor Lymphocyte Infusion

Coverage

Transplants are generally covered per the indications listed below and per your plan documents. The list of covered transplants is subject to periodic review and modification by the HealthPartners medical director or his or her designee.

Indications that are eligible for coverage

The following transplants are eligible for coverage:

  1. Kidney transplants for end stage disease.
  2. Heart transplants for end stage disease.
  3. Lung transplants or heart/lung transplants for:
    1. Primary pulmonary hypertension;
    2. Eisenmenger's syndrome;
    3. End stage pulmonary fibrosis;
    4. Alpha 1 antitrypsin disease;
    5. Cystic fibrosis;
    6. Emphysema.
  4. Liver transplants for:
    1. Biliary atresia in children;
    2. Primary biliary cirrhosis;
    3. Chronic hepatitis A, B, or C resulting in acute liver failure, cirrhosis or post necrotic cirrhosis;
    4. Primary sclerosing cholangitis;
    5. Alcoholic cirrhosis,
    6. Hepatocellular carcinoma.
  5. Simultaneous pancreas-kidney transplant(SPK), pancreas after kidney transplant (PAK), and living related segmental simultaneous pancreas kidney transplantation, as treatment for diabetic patients with renal disease.
  6. Pancreas transplant alone (PTA) for treatment of diabetes when the following indications are met:
    1. A history of frequent, acute and severe metabolic complications, such as hypoglycemia, hyperglycemia, or ketoacidosis requiring medical attention.
    2. Clinical and emotional problems with exogenous insulin therapy that are severe enough to be incapacitating, such as hypoglycemic unawareness.
    3. Consistent failure of insulin-based management to prevent acute complications.
  7. Small bowel transplantation on a case by case basis.
  8. Allogeneic bone marrow transplants or blood stem cell support (myeloablative or non-myeloablative) associated with high dose chemotherapy for:
    1. Acute lymphocytic leukemia;
    2. Chronic myelogenous leukemia;
    3. Severe combined immunodeficiency disease;
    4. Wiskott-Aldrich syndrome;
    5. Aplastic anemia;
    6. Acute myelogenous leukemia.
    7. Sickle Cell Anemia;
    8. Non-relapsed or relapsed non-Hodgkin's Lymphoma;
    9. Multiple Myeloma;
    10. Myelodysplastic syndromes associated with intermediate, high or very high revised international prognostic scoring system (IPSS-R) scores
  9. Autologous bone marrow transplants or blood stem cell support associated with high dose chemotherapy for the following:
    1. Acute leukemias;
    2. Non-Hodgkin's Lymphoma;
    3. Hodgkin's Disease;
    4. Burkitt's Lymphoma;
    5. Neuroblastoma.
    6. Multiple myeloma;
    7. Chronic myelogenous leukemia;
    8. Nonrelapsed non-Hodgkin's lymphoma.
    9. Immunoglobulin light chain (AL) amyloidosis
    10. Testicular cancer
  10. Donor Lymphocyte Infusion following a relapsed allogeneic bone marrow or blood stem cell transplantation.
Indications not covered

The following are not covered because they are considered experimental/investigational.

  1. Hand transplants
  2. Face transplants
  3. Uterine transplants

Definitions

Autologous bone marrow or stem cell transplant refers to harvesting the bone marrow or stem cells from the patient and storing it for future use. The patient undergoes treatment including tumor ablation with high-dose chemotherapy and/or radiation. After the treatment, the bone marrow or stem cells are reinfused (transplanted) into the patient.

Allogeneic bone marrow or stem cell transplant refers to harvesting the bone marrow or stem cells from a related or unrelated donor and storing it for future use. The patient undergoes treatment including tumor ablation with high-dose chemotherapy and/or radiation. After the treatment, the bone marrow or stem cells are reinfused (transplanted) into the patient.

Transplant Center of Excellence is any health care provider, group or association of health care providers designated by HealthPartners to provide services, supplies or drugs for the specified transplant performed on a covered person. For more information, please select the link under Transplants, Related Policies titled, “Transplant Resources and COE Networks”.

Donor lymphocyte infusion (DLI) therapy is usually done after an allogeneic bone marrow transplant (BMT) has failed. The DLI procedure involves taking a blood donation from the original bone marrow or peripheral blood stem cell donor. This blood is separated and certain white cells (lymphocytes) are selected to give to the patient. The goal of the therapy is to assist in remission or recovery of the patient's bone marrow.

Evaluation period is the first step in the process for the patient transplant candidate. The transplant program will schedule visits for biopsychosocial assessments based on protocols.

Listing or treatment period occurs when the evaluation is complete and the patient is deemed a transplant candidate. The program places the patient on a national waiting list or will initiate the blood and marrow treatment protocol.

Transplant services include the transplant (or re-transplant) of the human organs or tissues listed below, including all related post-surgical treatment and drugs and multiple transplants for a related cause. Transplant services do not include other organ or tissue transplants or surgical implantation of mechanical devices functioning as human organs, except surgical implantation of FDA approved ventricular assist devices (VAD), functioning as a temporary bridge to heart transplantation or as destination therapy for members end stage heart failure meeting the criteria specified in the VAD coverage policy. (See the VAD policy by selecting the link under Transplants, Related Policies titled “Ventricular Assist Device- VAD”.)

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

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

33935

Heart- lung transplant with recipient cardiectomy- pneumonectomy

33945

Heart transplant, with or without recipient cardiectomy

38240

Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor

38241

Hematopoietic progenitor cell (HPC); autologous transplantation

38242

Allogeneic lymphocyte infusions

38243

Hematopoietic progenitor cell (HPC); HPC boost

44135

Intestinal allotransplantation; from cadaver donor

47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age

47399

Unlisted procedure, liver

48160

Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells

48554

Transplantation of pancreatic allograft

50360

Renal allotransplantation, implantation of graft; without recipient nephrectomy

50365

Renal allotransplantation, implantation of graft; with recipient nephrectomy

50380

Renal autotransplantation, reimplantation of kidney

S2053

Transplantation of small intestine and liver allografts

S2065

Simultaneous pancreas kidney transplantation

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Alhamad, T., Stratta, R. Pancreas-kidney transplantation in diabetes mellitus: Benefits and complications In: UpToDate, Brennan, D., Nathan, D., UpToDate, Waltham, MA. (Accessed on November 29, 2018.)
  2. Brännström M, et al. Livebirth after uterus transplantation. Lancet, 385(9968):607-16 2015 Feb
  3. Breidenbach, W., Meister, E., Becker, G., Turker, T., Gorantla, V., Hassan,K,, Kaplan, B.2016, A Statistical Comparative Assessment of Face and Hand Transplantation Outcomes to Determine Whether Either Meets the Standard of Care Threshold Plastic and Reconstructive Surgery Journal, Volume 137, Number 1
  4. Chung, K., Yoneda, H. Upper extremity amputation. In: UpToDate, Berman, R.(Ed), Butler, C. (Ed) UpToDate, Waltham, MA. (Accessed on December 13, 2018).
  5. Ciberia, M., Sanchorawala, V., Seldin, D., Quillen, K., Berk, J.,Dember, L….Skinner, M, 2011. Outcome of AL amyloidosis after high-dose melphalan and autologous stem cell transplantation: long-term results in a series of 421 patients, Blood, October 2011, Volume 118, Number 16.
  6. Deeg, H., Sandmaier B., Determining eligibility for allogeneic hematopoietic cell transplantation. In: UpToDate, Chao, N. (Ed), UpToDate, Waltham, MA. (Accessed on December 12, 2018.)
  7. Diaz-Siso JR, et al. Facial allotransplantation: a 3-year follow-up report. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 66(11):1458-63 2013 Nov
  8. Diaz-Siso, Rodriguez, E. , 2016 Facial transplantation: knowledge arrives, questions remain, The Lancet Volume 388, Issue 10052, pages 1355-1356
  9. Dove, L., Brown, R., Liver transplantation in adults: Patient selection and pretransplantation evaluation In: UpToDate, Lindo, K. (Ed), UpToDate, Waltham, MA. (Accessed on November 30,2018.)
  10. ECRI Institute. (2017). Criteria for Kidney Transplantation Patients, Plymouth Meeting, PA: ECRI Institute.
  11. Elliot, R., Tintle, S., Levin, L. 2013 Upper extremity transplantation: current concepts and challenges in an emerging field, Current Reviews in Musculoskeletal Medicine March 2014, 7 (1): 83-88
  12. Erlichman, J., Loomes K., Biliary atresia In: UpToDate, Rand, E. (Ed), UpToDate, Waltham, MA. (Accessed on November 30, 2018.)
  13. Estey, E., Schrier, S. Treatment of high or very high risk myelodysplastic syndrome In: UpToDate, Larson, R., (ed) UpToDate, Waltham, MA. (Accessed on November 29, 2018.)
  14. Farrell R, et al. Uterine transplant: new medical and ethical considerations. Lancet 385 (pp581-82) 2015 Feb
  15. Fischer S, et al. Functional outcomes of face transplantation. American Journal of Transplantation, 15 (1) (pp 220-233) 2015 Jan
  16. Gilligan, T., Kantoff, P.. Diagnosis and treatment of relapsed and refractory testicular germ cell tumors. In: UpToDate, Oh, W. (Ed), UpToDate, Waltham, MA. (Accessed on December 12, 2018.)
  17. Gruessner R., Gruessner A., 2013 Pancreas Transplant Alone, A procedure coming of age Diabetes Care, Volume 36
  18. Hachem, R., Lung Transplantation: Disease-based choice of procedure In: UpToDate, Trulock, E. (Ed), UpToDate, Waltham, MA. (Accessed on December 20, 2018.)
  19. Hachem, R., Lung Transplantation: General guideline for recipient selection In: UpToDate, Trulock, E. (Ed), UpToDate, Waltham, MA. (Accessed on December 20, 2018.)
  20. Hayes, Inc. Hayes Medical Technology Directory Report. High-Dose Chemotherapy with Autologous Stem Cell Transplantation, Treatment for Germ Cell Testicular Transplantation Lansdale, PA: Hayes, Inc.; October 1998. Reviewed October 2005/Archived January 2006.
  21. Hayes, Inc. Hayes Medical Technology Directory Report. High-Dose Chemotherapy with Autologous Stem Cell Support, Treatment for Neuroblastoma Lansdale, PA: Hayes, Inc.; May, 2000. Reviewed October 2006/Archived January 2007.
  22. Hayes, Inc. Hayes Medical Technology Directory Report. Pancreas-After-Kidney (PAK) Transplantation in Diabetic Patients. Lansdale, PA: Hayes, Inc.; June, 2006 Reviewed June 2010/Archived July 2011.
  23. Holmberg, L., Deeg, H., Sandmaier, B. Determining eligibility for autologous hematopoietic cell transplantation In: UpToDate, Chao, N.(Ed) UpToDate, Waltham, MA. (Accessed on November 12, 2018.)
  24. Infante-Cossio P, et al. Facial transplantation: A concise update. Medicina Oral, Patologia Oral y Cirugia Bucal, 18(2) (ppe263-e271) 2013 Mar
  25. Järvholm s, et al. Uterus transplantation trial: Psychological evaluation of recipients and partners during the post-transplantation year. Fertil Steril. 104(4):1010-5 2015 Oct
  26. Johannesson L, et al. Uterus transplantation trial: 1-year outcome. Fertil Steril, 103(1):199-204 2015 Jan
  27. Kesseli, S., Sudan, D. 2018 Small Bowel Transplantation Surgical Clinics of North America, 99 103-116
  28. Khalifian, S, et al. Facial transplantation: the first 9 years. Lancet, 13;384(9960): 2153-63 2014 Apr
  29. Khan, F., Selveggi, G., Overview of intestinal and multivisceral transplantation In: UpToDate, Brown, R. (Ed), UpToDate, Waltham, MA. (Accessed on November 29, 2018).
  30. Lantieri L, et al. Face Transplant: long-term follow-up and results of a prospective open study. The Lancet Volume 388, Issue 10052 1398-1407 2016 Jan
  31. MacKay, B., Nacke E., Posner, M. 2014 Hand Transplantation: A review, Bulletin of the Hospital for Joint Diseases , 72 (1): 76-88
  32. Majhail N., Farnia, S., Carpenter, P., Champlin, R.,Crawford, S., Marks, D….LeMaistre, C. 2015 Indications for Autologous and Allogeneic Hematopoietic Cell Transplantation: Guidelines from the American Society for Blood and Marrow Transplantation, Biology of Blood and Marrow Transplantation, 21 1863-1869
  33. Malcovati, L., Hellstron-Lindberg E., Bowen D., Ades L., Cermak, J., Del Canizo, C…..Cazzola, M. 2013 Diagnosis and Treatment of primary myelodysplastic syndromes in adults: recommendations for the European LeukemiaNet, Blood, Volume 122, Number 17
  34. Martin, P., DiMartini A., Feng, S., Brown, R., Fallon , M. 2014 Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation Hepatology, Volume 59, No. 3
  35. Negrin, R., Hematopoietic cell transplantation in myelodysplastic syndromes In: UpToDate, Chao, N. (Ed), UpToDate, Waltham, MA. (Accessed on December 11, 2017.)
  36. National Institute for Health and Care Excellence (2011) Hand allotransplantation Retrieved from nice.org.uk/guidance/ipg383,
  37. Rajukumar, S., Dispenzieri, A. Treatment and prognosis of immunoglobulin light chain (AL) amyloidosis and light and heavy chain deposition diease In: UpToDate, Glassoic, R., Kyle, R., Schwab, S. (Ed), UpToDate, Waltham, MA. (Accessed on November 29, 2018).
  38. Rajkumar, S., Allogeneic hematopoietic cell transplantation in multiple myeloma, In: UptoDate, Kyle, R. (Ed) Waltham, MA (Accessed December 12, 2018)
  39. Robertson, R., Davis, C., Larsen, J., Stratta, R. Sutherland, S., 2006, Position statement: Pancreas and Islet Transplantation in Type 1 Diabetes, American Diabetes Association, Diabetes Care, volume 29, Number 4
  40. Robertson, R., Pancreas and islet transplantation in diabetes mellitus, In: UpToDate, Hirsch, I. (Ed), UpToDate, Waltham, MA. (Accessed on November 29, 2018)
  41. Roche NA, et al. Complex facial reconstruction by vascularized composite allotransplantation: the first Belgian case. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 68(3):362-71, 2015 Mar
  42. Salminger, S., Roche, A.D., Struma, A., Aszmann, O., 2016, Hand Transplantation Versus Hand Prosthetics: Pros and Cons, Current Surgery Reports, 4: 8
  43. Sanchorawala, V. 2014, High Dose Melaphan and Autologous Peripheral Blood Stem Cell Transplantation in AL Amyloidosis, Hematology/Oncology Clinics of North America, Volume 28, Issue 6, pages 1131-1144.
  44. Shanmugarajah, K, et al. Clinical outcomes of facial transplantation: A review. International Journal of Surgery, 9 (2011) 600-607.
  45. Shores, J., Malek, V., Andrew Lee, W.P., Brandacher, G. Tissue regeneration or regeneration of engineered tissue? Outcomes after hand and upper extremity transplantation, 2017 Journal of Materials Science,28:72
  46. Siemionow M, et al. Successes and lessons learned after more than a decade of upper extremity and face transplantation. Current Opinion in Organ Transplantation, 18(6) (pp 633-639) 2013 Dec.

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Policy activity

  • 07/01/1995 - Date of origin
  • 01/01/2019 - Effective date
Review date
  • 11/2018
Revision date
  • 10/15/2018

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