BlueCross and BlueShield of Montana Medical Policy/Codes
Lung and Lobar Lung Transplant
Chapter: Transplant
Current Effective Date: October 25, 2013
Original Effective Date: July 09, 2008
Publish Date: October 25, 2013
Revised Dates: March 1, 2010; March 26, 2012; January 17, 2013; September 25, 2013
Description

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.
Policy

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.

Coverage

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
  • Sarcoidosis
  • Scleroderma
  • Lymphangiomyomatosis
  • Emphysema
  • Eosinophilic granuloma
  • Bronchiolitis obliterans
  • Recurrent pulmonary embolism
  • Pulmonary hypertension due to cardiac disease
  • Chronic obstructive pulmonary disease
  • Eisenmenger's syndrome
  • Interstitial pulmonary fibrosis

Rationale

Lung transplantation is an established procedure for end stage pulmonary disease.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

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

ICD-10 Codes
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 
Procedural Codes: 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
References
  1. Lung Transplantation (Single and Double) TEC Assessment Program (June 1991) 80-145
  2. Lobar Lung transplantation for End-Stage Pulmonary Disease in Children and Adolescents TEC Assessment Program, (January 1996) 10(23), 1-7.
  3. Starnes VA, Woo MS, MacLaughlin EF, Horn MV, Wong PC, Rowland JM, Durst CL, Wells WJ, Barr ML, Comparison of outcomes between living donor and cadaveric lung transplantation in children Annals of Thoracic Surgery (1999 December) 68(6): 2279-83.
  4. Vizza CD, Yusen RD, Lynch JP, Fedele F, Alexander Patterson G, Trulock EP, Outcome of patients with cystic fibrosis awaiting lung transplantation American Journal of Respiratory and Critical Care Medicine (2000 September) 162 (3 Pt 1): 819-25
History
March 2012 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 
January 2013 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.
October 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Transplant: Lung and Lobar Lung Transplant" to "Lung and Lobar Lung Transplant".
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Lung and Lobar Lung Transplant