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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

Designated Transplant Providers HealthPartners Centers of Excellence
Many plans require that transplant procedures be performed at HealthPartners Designated Transplant Centers. Some plans allow for use of non-designated transplant facilities. Check your plan documents 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 Designated Transplant Centers.

For more information, please see the Related content at right for the HealthPartners Designated Transplant Centers. HealthPartners has local and national designated transplant centers.

Require prior notification

Prior notification at the time of transplant consultation is required 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 and bone marrow transplants for diagnoses listed below under Indications that are Covered, #8 and #9.
Require prior authorization

Prior authorization is required 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, #1 through #9.
  4. Pancreas transplant alone (PTA)
  5. Small bowel transplant
  6. Multiple organ transplants
Does Not Require Prior Authorization or Prior Notification
  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 Covered

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. Post-acute viral infection (including hepatitis A, hepatitis B antigen e negative and hepatitis C causing acute atrophy or post-necrotic cirrhosis;
    4. Primary sclerosing cholangitis;
    5. Alcoholic cirrhosis,
    6. Hepatocellular carcinoma.
  5. Pancreas transplants for simultaneous pancreas-kidney transplants for diabetes, pancreas after kidney, and living related segmental simultaneous pancreas kidney transplantation.
  6. Pancreas transplant alone (PTA) 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 so severe as 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. Testicular cancer.
  9. Autologous bone marrow transplants or blood stem cell support associated with high dose chemotherapy for the following (list may not be all-inclusive):
    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. Non relapsed non-Hodgkin's lymphoma.
  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.

A Designated Transplant Center 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, “Designated Transplant Centers”.

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.

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

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

48999

Unlisted procedure, pancreas

50360

Renal allotransplantation, implantation of graft; without recipient nephrectomy

50365

Renal allotransplantation, implantation of graft; with recipient nephrectomy

50380

Renal autotransplantation, reimplantation of kidney

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. Shanmugarajah, K, et al. Clinical outcomes of facial transplantation: A review. International Journal of Surgery, 9 (2011) 600-607.
  2. 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
  3. Fischer S, et al. Functional outcomes of face transplantation. American Journal of Transplantation, 15 (1) (pp 220-233) 2015 Jan
  4. Khalifian, S, et al. Facial transplantation: the first 9 years. Lancet, 13;384(9960): 2153-63 2014 Apr
  5. Van Lierde KM, et al. Speech Characteristics one year after first Belgian facial transplantation. Laryngoscope, 124(9):2021-7 2014 Sep
  6. 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
  7. 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
  8. Infante-Cossio P, et al. Facial transplantation: A concise update. Medicina Oral, Patologia Oral y Cirugia Bucal, 18(2) (ppe263-e271) 2013 Mar
  9. 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
  10. Brännström M, et al. Livebirth after uterus transplantation. Lancet, 385(9968):607-16 2015 Feb
  11. Farrell R, et al. Uterine transplant: new medical and ethical considerations. Lancet 385 (pp581-82) 2015 Feb
  12. Johannesson L, et al. Uterus transplantation trial: 1-year outcome. Fertil Steril, 103(1):199-204 2015 Jan
  13. Erman A, et al. Clinical pregnancy after uterus transplantation. Fertil Steril, 100(5): 1358-63 2013 Nov
  14. Del Priore G, et al. Uterine transplantation—a real possibility? The Indiana consensus. Human Reproduction. 28(2):288-91 2013 Feb
  15. 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

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Policy activity

  • 07/01/1995 - Date of origin
  • 02/10/2017 - Effective date
Review date
  • 01/2017
Revision date
  • 03/08/2016

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