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Medicare Advantage Prior Authorization
Transplants

last updated 06/30/2014garcarl

29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral
38232 Bone marrow harvesting for transplantation; autologous
38243 Hematopoietic progenitor cell (HPC); HPC boost
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 
33930 Donor cardiectomy-pneumonectomy (including cold preservation) 
33933 Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation
33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy 
33940 Donor cardiectomy (including cold preservation) 
33944 Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation 
33945 Heart transplant, with or without recipient cardiectomy
38204 Management of recipient hematopoietic progenitor cell donor search and cell acquisition 
38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic 
38206 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous 
38208 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing
38209 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing 
38210 Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion
38211 Transplant preparation of hematopoietic progenitor cells; tumor cell depletion 
38212 Transplant preparation of hematopoietic progenitor cells; red blood cell removal
38213 Transplant preparation of hematopoietic progenitor cells; platelet depletion 
38214 Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion 
38215 Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer
38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic 
38241 Bone marrow or blood-derived peripheral stem cell transplantation; autologous 
38242 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions 
44715 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
44720 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each 
44721 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each 
44799 Unlisted procedure, intestine 
47144 including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII]) 
47145 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (ie, left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII]) 
48550 Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation 
48551 Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery 
48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each 
48554 Transplantation of pancreatic allograft 
48556 Removal of transplanted pancreatic allograft
48999 Unlisted procedure, pancreas
50300 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral 
50320 Donor nephrectomy (including cold preservation); open, from living donor 
50323 Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary 
50325 Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary 
50327 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
50328 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each
50329 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each 
50340 Recipient nephrectomy (separate procedure)
50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy 
50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy 
50370 Removal of transplanted renal allograft 
50380 Renal autotransplantation, reimplantation of kidney 
G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion 
G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion 
G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion 

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