Lung and Lobar Lung Transplant
© Blue Cross and Blue Shield of Montana
Current Effective Date:
October 25, 2013
Original Effective Date:
July 09, 2008
October 25, 2013
March 1, 2010; March 26, 2012; January 17, 2013; September 25, 2013
A lung transplant refers to single-lung or double-lung replacement. In a single-lung transplant, only one lung from a cadaver donor is provided to the recipient. In a double-lung transplant, both lungs are removed and replaced by the donor's lungs.
In a lobar transplant, a lobe of the donor's lung is excised, sized appropriately for the recipient's thoracic dimensions and then transplanted. Donors for lobar transplant have been primarily living related donors, with one lobe obtained from each of two donors (e.g. mother and father) in cases where a bilateral transplant is required; there are also cases of cadaver lobe transplants.
Patients are required to meet the following physical status criteria for any type of lung transplant:
- No history of primary or metastatic malignancies within the last 5 years
- Absence of HIV infection
- Absence of on-going smoking
- Absence of substance abuse
- Documentation of compliance with medical therapy.
Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.
Lung transplantation (single or double) is considered medically necessary for carefully selected patients with irreversible, progressively disabling, end-stage pulmonary disease.
A lobar lung transplant is considered medically necessary for children and adolescents with endstage pulmonary disease.
The following list includes (but is not limited to) conditions where lung transplantation or lobar lung transplantation is considered medically necessary:
- Bilateral bronchiectasis
- Alpha-1 antitrypsin deficiency
- Primary pulmonary hypertension
- Pulmonary fibrosis
- Cystic fibrosis (both lungs to be transplanted)
- Bronchopulmonary dysplasia
- Idiopathic pulmonary fibrosis
- Eosinophilic granuloma
- Bronchiolitis obliterans
- Recurrent pulmonary embolism
- Pulmonary hypertension due to cardiac disease
- Chronic obstructive pulmonary disease
- Eisenmenger's syndrome
- Interstitial pulmonary fibrosis
33.50, 33.51, 33.52, 494.0, 494.1, 748.61, 277.6, 416.0, 277.00, 277.01, 770.7, 516.3, 135, 517.8, 710.1, 235.7, 492.8, 277.8, 491.8, 415.1, 402.10, 496, 745.4, 515
A15.0, C96.6, D48.1, D86.0, D86.2, E84.0-E84.9, E88.01, I26.01-I26.99, I27.0, I27.2, I27.82, I27.89, J42, J43.0-J43.9, J44.9, J47.0-J47.1, J60-J70.9, J84.1, M34.0-M34.9, P27.0-P27.9, Q33.0-Q33.9, 0BYK0Z0, 0BYK0Z1, 0BYL0Z0, 0BYL0Z1, 0BYM0Z0, 0BYM0Z1
32850, 32851, 32852, 32853, 32854, 32855, 32856, 33933, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86849, S2152
Lung Transplantation (Single and Double) TEC Assessment Program (June 1991) 80-145
||Policy updated with literature review. Absolute contraindications moved to Policy Guidelines and combined with relative complications; wording consistent with other transplant policies. References 2, 3, 8, 18 and 19 added; other references renumbered or removed |
||Policy updated with literature review. In lobar lung statement, “children and adolescents” replaced with “carefully selected patients.” In this policy statement, codes were update for idiopathic/interstitial pulmonary fibrosis and emphysema. References 8, 12, 13, 21-24 added; other references renumbered or removed.|
||Policy formatting and language revised. Policy statement unchanged. Title changed from "Transplant: Lung and Lobar Lung Transplant" to "Lung and Lobar Lung Transplant".|