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MP 7.03.07 Lung and Lobar Lung Transplant

Medical Policy    
Section
Surgery
 
Original Policy Date
7/31/96
 
Last Review Status/Date
Reviewed with literature search/12:2012
Issue
12:2012
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

A lung transplant consists of replacing all or part of diseased lungs with healthy lung(s). Transplantation is an option for patients with end-stage lung disease.

End-stage lung disease may be the consequence of a number of different etiologies. The most common indications for lung transplantation are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. Prior to the consideration for transplant, patients should be receiving maximal medical therapy, including oxygen supplementation, or surgical options, such as lung-volume reduction surgery for COPD. Lung or lobar lung transplantation is an option for patients with end-stage lung disease despite these measures.

A lung transplant refers to single-lung or double-lung replacement. In a single-lung transplant, only one lung from a deceased donor is provided to the recipient. In a double-lung transplant, both the recipient's 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 transplanted. Donors for lobar transplant have primarily been living-related donors, with one lobe obtained from each of two donors (e.g., mother and father) in cases for which bilateral transplantation is required. There are also cases of cadaver lobe transplants. Combined lung-pancreatic islet cell transplant is being studied for patients with cystic fibrosis. (1)

Since 2005, potential recipients have been ranked according to the Lung Allocation Score (LAS). (2) Patients 12 years of age and older receive a score between 1 and 100 based on predicted survival after transplantation reduced by predicted survival on the waiting list; the LAS takes into consideration the patient’s disease and clinical parameters. In 2010, a simple priority system was implemented for children younger than age 12 years. Under this system, children younger than 12 with respiratory lung failure and/or pulmonary hypertension who meet criteria are considered “priority 1” and all other candidates in the age group are considered “priority 2.” A lung review board has the authority to adjust scores on appeal for adults and children.


Policy

Lung transplantation may be considered medically necessary for carefully selected patients with irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximum medical therapy, including but not limited to one of the conditions listed below.

A lobar lung transplant from a living or deceased donor may be considered medically necessary for carefully selected patients with end-stage pulmonary disease including but not limited to one of the conditions listed below.

  CODES 
Bilateral bronchiectasis   494.0-494.1
 
748.61 for congenital bronchiectasis 
 
Alpha-1 antitrypsin deficiency  273.4
Primary pulmonary hypertension  416.0 
Cystic fibrosis (both lungs to be transplanted)  277.00 – 277.09
Bronchopulmonary dysplasia  770.7 
Interstitial pulmonary fibrosis  515 
Idiopathic pulmonary fibrosis  516.30, 516.31
Sarcoidosis  135; 517.8 
Scleroderma  710.1; 517.2
Lymphangiomyomatosis  238.1
Emphysema   492.8; 491.20-491.22; 518.1,518.2
Eosinophilic granuloma  277.89
Bronchiolitis obliterans  491.8 
Recurrent pulmonary embolism  416.2; 415.11-415.19
Pulmonary hypertension due to cardiac disease  416.8
Chronic obstructive pulmonary disease  496 
Eisenmenger’s syndrome  745.4 
 

Policy Guidelines

General

Potential contraindications subject to the judgment of the transplant center:

  1. Known current malignancy, including metastatic cancer
  2. Recent malignancy with high risk of recurrence
  3. Untreated systemic infection making immunosuppression unsafe, including chronic infection
  4. Other irreversible end-stage disease not attributed to lung disease
  5. History of cancer with a moderate risk of recurrence
  6. Systemic disease that could be exacerbated by immunosuppression
  7. Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Policy-specific

  1. Coronary artery disease (CAD) not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function*; or
  2. Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.

*Some patients may be candidates for combined heart-lung transplantation (see policy No. 7.03.08)

Patients must meet United Network for Organ Sharing (UNOS) guidelines for lung allocation score (LAS) greater than zero.

Lung Specific

Bilateral lung transplantation is typically required when chronic lung infection disease is present, i.e., associated with cystic fibrosis and bronchiectasis. Some, but not all, cases of pulmonary hypertension will require bilateral lung transplantation.

Bronchiolitis obliterans is associated with chronic lung transplant rejection, and thus may be the etiology of a request for lung retransplantation.


Benefit Application
BlueCard/National Account Issues

Lung transplants should be considered for coverage under the Transplant benefit.

What is covered under the scope of the Human Organ Transplant (HOT) benefit needs to be considered. Typically, the following are covered under the HOT benefit:

  • hospitalization of the recipient for medically recognized transplants from a donor to a transplant recipient;
  • evaluation tests requiring hospitalization to determine the suitability of both potential and actual donors, when such tests cannot be safely and effectively performed on an outpatient basis;
  • hospital room, board, and general nursing in semi-private rooms;
  • special care units, such as coronary and intensive care;
  • hospital ancillary services;
  • physicians’ services for surgery, technical assistance, administration of anesthetics, and medical care;
  • acquisition, preparation, transportation, and storage of organ;
  • diagnostic services;
  • drugs that require a prescription by federal law.

Expenses incurred in the evaluation and procurement of organs and tissues are benefits when billed by the hospital. Included in these expenses may be specific charges for participation with registries for organ procurement, operating rooms, supplies, use of hospital equipment, and transportation of the tissue or organ to be evaluated.

Administration of products with a specific transplant benefit needs to be defined as to:

  • when the benefit begins (at the time of admission for the transplant or once the patient is determined eligible for a transplant, which may include tests or office visits prior to transplant);
  • when the benefit ends (at the time of discharge from the hospital or at the end of required follow-up, including the immunosuppressive drugs administered on an outpatient basis).

Coverage usually is not provided for:

  • HOT services for which the cost is covered/funded by governmental, foundational, or charitable grants;
  • organs sold rather than donated to the recipient;
  • an artificial organ.


Rationale 

Literature Review

This policy was originally created in 1996 and updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period of October 2011 through October 2012. Due to the nature of the population, there are no randomized controlled trials (RCTs) that compare lung transplantation with alternatives. Systematic reviews are based on case series and registry data. The extant RCTs compare surgical technique, infection prophylaxis, or immunosuppressive therapy and are not germane to this policy. The following is a summary of the evidence based on registries, case series, and expert opinion.

Survival

The Registry of the International Society for Heart and Lung Transplantation (ISHLT) had reports from centers around the world of 3,272 lung transplants performed in 2009. (3) The overall median survival of patients who underwent lung transplantation between 1994 and June 2010 was 5.5 years. In the first 30 days after transplantation and the first year, the major reported causes of mortality were graft failure and non-cytomegalovirus (CMV) infections. Beyond the first year, the most common reported causes of mortality were bronchiolitis obliterans and non-CMV infections. Over time, the proportion of patients who died from malignancies increased; malignancies accounted for 15% of all deaths between 5 and 10 years after transplant. Authors of a 2009 review of the current status of lung transplantation observed that while transplantation can prolong survival, survival statistics for lung transplantation are not as favorable as in patients receiving other solid organ transplants. (4)

In 2009, Thabut and colleagues reported on a comparison of patients undergoing single- and double-lung transplantation for idiopathic pulmonary fibrosis. (5) A retrospective review was conducted of 3,327 patients with data in the UNOS registry. More patients underwent single-lung as compared to double-lung transplant (64.5 vs. 35.5%, respectively). Median survival time was greater for the double-lung group at 5.2 years (95% confidence interval [CI]: 4.3 to 6.7 years) versus 3.8 years (95% CI: 3.6 to 4.1 years; p<0.001). After adjustment for baseline differences, however, survival times were not statistically different. The authors concluded that overall survival did not differ between the 2 groups: single-lung transplants offered improved short-term survival but long-term harm, whereas double-lung transplant increased short-term harm but was associated with a long-term survival benefit.

Patient Selection

In 2008, Kozower and colleagues performed a retrospective cohort study using data from 5 academic medical centers to evaluate the impact of a new lung allocation score on short-term outcomes after lung transplantation. (6) (This lung allocation score was implemented in May 2005 by the Organ Procurement and Transplantation Network [OPTN].) This new score changed lung allocation from a system based on waiting time to an algorithm based on the probability of survival for 1 year on the transplant list and survival 1-year post-transplantation. Results were compared for 170 patients who received transplants on the basis of the new lung allocation scores (May 4, 2005 to May 3, 2006) with those of 171 patients who underwent transplants the preceding year before implementation of the scoring system. Waiting time decreased from 681 to 445.6 days (p<0.001). Recipient diagnoses changed, with an increase (15% to 25%) in idiopathic pulmonary fibrosis cases and decreases in emphysema (46% to 34%) and cystic fibrosis (23% to 13%). Hospital mortality and 1-year survival were the same between groups (5.3% vs. 5.3% and 90% vs. 89%, respectively). Presumably due to increased severity of illness, the incidence of primary graft dysfunction and postoperative intensive care unit length of stay increased in the year after implementation of the scoring system; graft dysfunction grew from 14.8% (24/170) to 22.9% (39/171); (p=0.04) and length of stay rose from 5.7 to 7.8 days.

In 2010, Yusen and colleagues reviewed the effect of the Lung Allocation Score (LAS) on lung transplantation by comparing statistics for the period before and after its implementation in 2005. (7) Other independent changes in clinical practice, which may affect outcomes over the same period of time, include variation in immunosuppressive regimens, an increased supply of donor lungs, changes in diagnostic mix, and increased consideration of older recipients. Deaths on the waiting list declined following implementation of the LAS system, from approximately 500 per 5,000 patients to 300 per 5,000 patients. However, it is expected that implementation of the LAS affected patient characteristics of transplant applicants. One-year survival post-transplantation did not improve after implementation of the LAS system: patient survival data before and after are approximately 83%. Long-term survival data are not yet available for comparison.

Pediatric Considerations

In 2012, Benden and colleagues reviewed pediatric lung transplants that have been reported to the international registry. (8) Pediatric patients are defined as those younger than 18 years of age. The authors noted an increase in the number of pediatric lung transplants in recent years; there were 126 transplants in 2010 compared to 73 in 2000. In contrast to adult patients, the most common indication for pediatric patients was cystic fibrosis, accounting for 54% of lung transplants in 6-11 year-olds and 72% of lung transplants in 12-17 year-olds that occurred between 1990 and June 2011. Survival has improved in the recent era, and 5-year survival is not significantly different from adult recipients. The half-life, estimated time at which 50% of recipients have died, was 4.7 years for children and 5.3 years for adults. For children receiving allografts between 2002 and June 2010, the 5-year survival rate was 54% and 7-year survival was 44%. Patients aged 1 to 11 years had a significantly better survival rate than those between the ages of 12 and 17 years (half-life of 6.2 years and 4.3 years, respectively). In the first year after lung transplantation, non-CMV infection and graft failure were the 2 leading causes of death. Bronchiolitis obliterans syndrome was the major cause of death beyond 3 years after transplantation.

Potential contraindications

Malignancy

Concerns regarding a potential recipient’s history of cancer have been based on the observation of significantly increased incidence of cancer in kidney transplant patients. (9) For renal transplant patients who had a malignancy treated prior to transplant, the incidence of recurrence ranged from zero to more than 25%, depending on the tumor type. (10, 11) However, it should be noted that the availability of alternative treatment strategies informs recommendations for a waiting period following high-risk malignancies: in renal transplant, a delay in transplantation is possible due to dialysis; end-stage lung disease patients may not have an option to defer.

A 2012 study reported on outcomes in patients with lung cancer who were lung transplant recipients. (12) Ahmad and colleagues identified 29 individuals in the UNOS database who underwent lung transplantation for advanced bronchoalveolar carcinoma (BAC). These patients represented 0.13% of the 21,553 lung transplantations during the study period. BAC and general lung transplant recipients had similar survival rates: the 30-day mortality rate was 7% versus 10% (p=0.44) and 5-year survival rate was 50% versus 57% (p=0.66), all respectively.

HIV

Solid organ transplant for patients who are human immunodeficiency virus (HIV)-positive has been controversial, due to the long-term prognosis for HIV positivity and the impact of immunosuppression on HIV disease. Although HIV-positive transplant recipients may be of research interest at some transplant centers, the minimal data regarding long-term outcome in these patients primarily consist of case reports and abstract presentations of liver and kidney recipients. Nevertheless, some transplant surgeons would argue that HIV positivity is no longer an absolute contraindication to transplant due to the advent of highly active antiretroviral therapy (HAART), which has markedly changed the natural history of the disease.

As of November 2010, the Organ Procurement Transplantation Network (OPTN) policy on HIV status in recipients states: “A potential candidate for organ transplantation whose test for HIV is positive should not be excluded from candidacy for organ transplantation unless there is a documented contraindication to transplantation based on local policy.” (13)

In 2006, the British HIV Association and the British Transplantation Society Standards Committee published guidelines for kidney transplantation in patients with HIV disease. (14) These criteria may be extrapolated to other organs:

  • CD4 count greater than 200 cells/ml for at least 6 months
  • Undetectable HIV viremia (less than 50 HIV-1 RNA copies/ml) for at least 6 months
  • Demonstrable adherence and a stable HAART regimen for at least 6 months
  • Absence of AIDS defining illness following successful immune reconstitution after HAART.

Other Infections

Infection with Burkholderia cenocepacia is associated with increased mortality in some transplant centers, a factor that may be taken into account when evaluating overall risk for transplant survival. (15) Two papers published in 2008 evaluated the impact of infection with various species of Burkholderia on outcomes for lung transplantation for cystic fibrosis. In a study published by Murray and colleagues, multivariate Cox survival models assessing hazard ratios (HRs) were applied to 1,026 lung transplant candidates and 528 transplant recipients. (16) Of the transplant recipients, 88 were infected with Burkholderia. Among transplant recipients infected with Burkholderia cenocepacia, only those infected with nonepidemic strains (n=11) had significantly greater post-transplant mortality than uninfected patients (HR: 2.52; 95% confidence interval [CI: 1.04-6.12; p=0.04). Transplant recipients infected with Burkholderia gladioli (n=14) also had significantly greater post-transplant mortality than uninfected patients (HR: 2.23; 95% CI: 1.05-4.74; p=0.04). When adjustments for specific species/strains were included, lung allocation scores of Burkholderia multivorans-infected transplant candidates were comparable to uninfected candidate scores, and scores for patients infected with non-epidemic B cenocepacia or B gladioli were lower. In a smaller study of 22 patients colonized with Burkholderia cepacia complex who underwent lung transplantation in two French centers, the risk of death by univariate analysis was significantly higher for the 8 patients infected with B cenocepacia than for the other 14 colonized patients (11 of whom had B multivorans). (17)

In 2012, Shields and colleagues reported on infections in 596 consecutive lung transplant recipients treated at a single center occurring in the first 90 days after transplantation. (18) A total of 109 patients (18%) developed 138 Staphylococcus aureus infections. The most common type of infection was pneumonia (66 of 138, 48%) followed by tracheobronchitis (36 of 138, 26%) and bacteremia (17 of 138, 12%). Thirteen of 109 (12%) of patients with Saureus infection died within 90 days of the onset of infection. The 1-year mortality rate was higher for patients with Saureus pneumonia (19 of 66, 29%) but not Saureus tracheobronchitis (8 of 36, 22%) compared with uninfected patients (85 of 487, 17%).

Pinney and colleagues published a retrospective review of invasive fungal infection rates in lung transplantation patients without cystic fibrosis treated at a single center. (19) Patients were followed for a median of 34 months. Invasive fungal infections were identified in 22 of 242 (9.1%) patients. Aspergillus infections were most common, occurring in 11 of 242 (4.5%) of patients. There were also 7 cases (3%) of Candida infection. Survival rates did not differ significantly in patients with invasive fungal infections compared to the entire cohort of patients. For example, 3-year survival was 50% among patients with invasive fungal infection and 66% in the entire cohort, p=0.66. The authors did not compare survival in patients with invasive fungal infections to survival only in those without invasive fungal infections.

Coronary Artery Disease (CAD)

In 2011, Sherman and colleagues reported on outcomes in 27 patients with CAD at a single center who underwent lung transplantation and coronary revascularization. (20) Patients needed to be otherwise considered good candidates for transplantation and have discrete coronary lesions (at least 50% in the left main artery or at least 70% in other major vessels) and preserved ejection fraction. Thirteen patients had single-lung transplantation and 14 had double-lung transplantation. Outcomes were compared with a control group of 81 patients without CAD who underwent lung transplantation; patients were matched for age, diagnosis, lung allocation score and type of procedure. During a mean follow-up of 3 years, 9 of 27 (33%) patients with CAD and 28 of 81 (35%) without CAD died, p=0.91. Bronchiolitis obliterans and infection were the primary causes of death. There was no significant difference between groups in a composite outcome of adverse cardiac events (defined as acute coronary syndrome, redo revascularization or hospital admissions for congestive heart failure), p=0.80.

Lobar lung transplantation

Several case series have reported outcomes after lobar lung transplants in both children and adults. In 2005, Barr and colleagues reported on experience performing living donor lobar lung transplants in the U.S. (21) Ninety patients were adults and 43 were children. The primary indication for transplantation (86%) was cystic fibrosis. At the time of transplantation, 67% of patients were hospitalized and 20% were ventilator dependent. Overall recipient actuarial survival at 1-, 3- and 5-years was 70%, 54% and 45%, respectively. There was not a statistically significant difference in actuarial survival between adults and children who underwent transplantation. Moreover, survival rates were similar to the general population of lung transplant recipients. The authors also reported that rates of postoperative pulmonary function in patients surviving more than 3 months post-transplant were comparable to rates in cadaveric lung transplant recipients.

In 2012, a program in Japan reported on 14 critically ill patients who had undergone single living-donor lobar lung transplants; there were 10 children and 4 adults. (22) Patients were followed for a mean 45 months. The 3-year survival rate was 70% and the 5-year survival was 56%. Severe graft dysfunction occurred in 4 patients. Mean forced vital capacity (FVC) was found to be lower in patients experiencing severe graft dysfunction compared to the other patients, mean FVC was 54.5% and 66.5%, respectively. The authors stated that this suggests size mismatching in the patients with severe graft dysfunction. Also in 2012, Inci and colleagues published data on 23 patients in Switzerland who received bilateral lobar lung transplants. (23) The mean age was 41 years (range: 13 to 66 years). Survival at 1 and 2 years was 82% and 64%, respectively; survival rates were comparable with 219 patients who underwent bilateral lung transplantation during the same time period (p=0.56).

A review article by Date stated that, as of 2011, approximately 400 living-donor lobar lung transplants have been performed worldwide. (24) Procedures in the U.S. decreased after 2005 due to changes in the lung allocation system. The author stated that size matching between donor and recipient is important and that, to some extent, size mismatching (oversized or undersized grafts) can be overcome by adjusting surgical technique.

Summary

The literature on lung and lobar lung transplantation, which consists of case series and registry data, demonstrates that lung and lobar lung transplantation provides a survival benefit in appropriately selected patients and thus may be considered medically necessary. It may be the only option for some patients with end-stage lung disease.

Practice Guidelines and Position Statements

In 2006, the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation published consensus-based guidelines on selection of lung transplant candidates (25) The guidelines state that, “Lung transplantation is now a generally accepted therapy for the management of a wide range of severe lung disorders, with evidence supporting quality of life and survival benefit for lung transplant recipients. However, the number of donor organs available remains far fewer than the number of patients with end-stage lung disease who might potentially benefit from the procedure. It is of primary importance, therefore, to optimize the use of this resource, such that the selection of patients who receive a transplant represents those with realistic prospects of favorable long-term outcomes. There is a clear ethical responsibility to respect these altruistic gifts from all donor families and to balance the medical resource requirement of one potential recipient against those of others in their society. These concepts apply equally to listing a candidate with the intention to transplant and potentially de-listing (perhaps only temporarily) a candidate whose health condition changes such that a successful outcome is no longer predicted.”

Medicare National Coverage

Lung transplantation is covered under Medicare when performed in a facility that is approved by Medicare as meeting institutional coverage criteria. (26) The Centers for Medicare and Medicaid Services have stated that under certain limited cases, exceptions to the facility-related criteria may be warranted if there is justification and the facility ensures safety and efficacy objectives.

References:

 

 

  1. Kessler L, Bakopoulou S, Kessler R et al. Combined pancreatic islet-lung transplantation: a novel approach to the treatment of end-stage cystic fibrosis. Am J Transplant 2010; 10(7):1707-12.
  2. United Network for Organ Sharing (UNOS). Questions and answers for professionals about lung allocation policy. Available online at: http://www.unos.org/docs/Lung_Professional.pdf. Last accessed November, 2012.
  3. Christie JD, Edwards LB, Kucheryavaya AY et al. The Registry of the International Society for Heart and Lung Transplantation: twenty-eighth official adult lung and heart-lung transplant report--2011. J Heart Lung Transplant 2011; 30(10):1104-22.
  4. Orens JB, Garrity Jr ER. General overview of lung transplantation and review of organ allocation. Proc Am Thorac Soc 2009; 6(1):13-9.
  5. Thabut G, Christie JD, Kremers WK et al. Survival differences following lung transplantation among US transplant centers. JAMA 2010; 304(1):53-60.
  6. Kozower BD, Meyers BF, Smith MA et al. The impact of the lung allocation score on short-term transplantation outcomes: a multicenter study. J Thorac Cardiovasc Surg 2008; 135(1):166-71.
  7. Yusen RD, Shearon TH, Qian Y et al. Lung transplantation in the United States, 1999-2008. Am J Transplant 2010; 10(4 Pt 2):1047-68.
  8. Benden C, Edwards LB, Kucheryavaya AY et al. The registry of the International Society for Heart and Lung Transplantation: fifteenth pediatric lung and heart-lung transplantation report--2012. J Heart Lung Transplant 2012; 31(10):1087-95.
  9. Kasiske BL, Snyder JJ, Gilbertson DT et al. Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4(6):905-13.
  10. Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. Am J Transplant 2005; 5(9):2079-84.
  11. Trofe J, Buell JF, Woodle ES et al. Recurrence risk after organ transplantation in patients with a history of Hodgkin disease or non-Hodgkin lymphoma. Transplantation 2004; 78(7):972-7.
  12. Ahmad U, Wang Z, Bryant AS et al. Outcomes for lung transplantation for lung cancer in the United Network for Organ Sharing Registry. Ann Thorac Surg 2012; 94(3):935-40; discussion 40-1.
  13. Organ Procurement and Transplantation Network (OPTN). Policy and Bylaws 4.0 Identification of Transmissible Diseases in Organ Recipients. Available online at: http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_16.pdf. Last accessed November, 2012.
  14. Bhagani S, Sweny P, Brook G. Guidelines for kidney transplantation in patients with HIV disease. HIV Med 2006; 7(3):133-9.
  15. Alexander BD, Petzold EW, Reller LB et al. Survival after lung transplantation of cystic fibrosis patients infected with Burkholderia cepacia complex. Am J Transplant 2008; 8(5):1025-30.
  16. Murray S, Charbeneau J, Marshall BC et al. Impact of burkholderia infection on lung transplantation in cystic fibrosis. Am J Respir Crit Care Med 2008; 178(4):363-71.
  17. Boussaud V, Guillemain R, Grenet D et al. Clinical outcome following lung transplantation in patients with cystic fibrosis colonised with Burkholderia cepacia complex: results from two French centres. Thorax 2008; 63(8):732-7.
  18. Shields RK, Clancy CJ, Minces LR et al. Staphylococcus aureus infections in the early period after lung transplantation: Epidemiology, risk factors, and outcomes. J Heart Lung Transplant 2012; 31(11):1199-206.
  19. Pinney ME, Rosenberg AF, Hampp C et al. Invasive fungal infections in lung transplant recipients not receiving routine systemic antifungal prophylaxis: 12-year experience at a university lung transplant center. Pharmacotherapy 2011; 31(6):537-45.
  20. Sherman W, Rabkin DG, Ross D et al. Lung transplantation and coronary artery disease. Ann Thorac Surg 2011; 92(1):303-8.
  21. Barr ML, Schenkel FA, Bowdish ME et al. Living donor lobar lung transplantation: current status and future directions. Transplant Proc 2005; 37(9):3983-6.
  22. Date H, Shiraishi T, Sugimoto S et al. Outcome of living-donor lobar lung transplantation using a single donor. J Thorac Cardiovasc Surg 2012; 144(3):710-5.
  23. Inci I, Schuurmans MM, Kestenholz P et al. Long-term outcomes of bilateral lobar lung transplantation. Eur J Cardiothorac Surg 2012 [Epub ahead of print].
  24. Date H. Update on living-donor lobar lung transplantation. Curr Opin Organ Transplant 2011; 16(5):453-7.
  25. Orens JB, Estenne M, Arcasoy S et al. International guidelines for the selection of lung transplant candidates: 2006 update--a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2006; 25(7):745-55.
  26. Medicare approved lung transplant centers. Available online at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf. Last accessed November, 2012.

 

Codes

Number

Description

CPT  32850  Donor pneumonectomy(ies) (including cold preservation), from cadaver donor 
  32851  Lung transplant, single; without cardiopulmonary bypass 
  32852  with cardiopulmonary bypass 
  32853  Lung transplant, double (bilateral, sequential, or en bloc); without cardiopulmonary bypass 
  32854  with cardiopulmonary bypass 
  32855  Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus, unilateral 
  32856  bilateral 
ICD-9 Procedure  32.50 Thoracoscopic pneumonectomy 
  32.59 Other and unspecified pneumonectomy
  32.6 Radical dissection of thoracic structures
  32.9 Other dissection of lung
  33.50 Lung transplantation, not otherwise specified
  33.51  Unilateral lung transplantation 
  33.52  Bilateral lung transplantation 
  39.61  Cardiopulmonary bypass 
ICD-9 Diagnosis  011.4  Tuberculous fibrosis of lung 
  500 – 505  Pneumoconiosis and other lung diseases due to external agents code range 
  506.4  Pulmonary fibrosis due to fumes and vapors 
  515  Pulmonary fibrosis, post-inflammatory 
    See codes for conditions in Policy Statement section 
HCPCS  S2060  Lobar lung transplantation 
  S2061  Donor lobectomy (lung) for transplantation, living donor 
ICD-10-CM (effective 10/1/14) A15.0 Tuberculosis of lung (includes tuberculous fibrosis of lung)
  C96.6 Unifocal Langerhans-cell histiocytosis (includes eosinophilic granuloma of lung)
  D48.1 Neoplasm of uncertain behavior of connective and other soft tissue (includes lymphangiomyomatosis)
  D86.0;D86.2 Sarcoidosis of lung and sarcoidosis of lung with sarcoidosis of lymph nodes, respectively
  E84.0-E84.9 Cystic fibrosis code range
  E88.01 Alpha-a-antitrypsin deficiency
  I26.01-I26.99 Pulmonary embolism code range
  I27.0 Primary pulmonary hypertension
  I27.2 Other secondary pulmonary hypertension (includes pulmonary hypertension due to cardiac disease)
  I27.82 Chronic pulmonary embolism
  I27.89 Other specified pulmonary heart diseases (includes Eisenmenger's syndrome)
  J42 Unspecified chronic bronchitis (includes bronchiolitis obliterans)
  J43.0-J43.9 Emphysema code range
  J44.9 Chronic obstructive pulmonary disease, unspecified Chronic obstructive pulmonary disease, unspecified
  J47.0-J47.1 Bronchiectasis, acute codes
  J60-J70.9 Lung diseases due to external agents code range (includes pneumoconiosis and pulmonary fibrosis due to fumes and vapors)
  J84.1 Other interstitial pulmonary diseases with fibrosis
  M34.0-M34.9 Systemic sclerosis [scleroderma] (especially M34.81 - Systemic sclerosis with lung involvement)
  P27.0-P27.9 Chronic respiratory disease originating in the perinatal period (includes bronchopulmonary dysplasia)
    Q33.0-Q33.9 Congenital malformations of lung code range (includes congenital bronchiectasis)
ICD-10-PCS (effective 10/1/14) 0BYK0Z0, 0BYK0Z1, 0BYL0Z0, 0BYL0Z1, 0BYM0Z0, 0BYM0Z1 Surgical, respiratory system, transplantation, open, code by body part (right, left or bilateral) and qualifier (allogeneic or syngeneic)
Type of Service  Surgery 
Place of Service  Inpatient 


Index

Lobar Lung Transplant
Lung and Lobar Lung Transplant
Lung Transplant, Single and Double
Transplant, Lobar Lung
Transplant, Lung


Policy History

Date Action Reason
07/31/96 Add to Surgery section, Transplants subsection New policy
12/18/02 Replace policy Policy updated; no change in policy statement
02/25/04 Replace policy Policy revised; policy statement revised to state that transplantation is investigational for HIV+ recipients. Additional criteria added to Policy Guidelines section to be consistent with other transplant policies
03/15/05 Replace policy Policy updated with literature review; no change in policy statement. Reference number 8 added
04/1/05 Replace policy Policy revised; HIV positivity deleted as an investigational indication for transplantation. Reference number 8 revised
9/27/05 Replace policy Policy corrected; HIV positivity statement removed from policy section and CPT coding updated
03/7/06 Replace policy Policy updated with literature review; no change in policy statement
04/09/08 Replace policy  Policy updated with literature review; references 9-11 added; policy guidelines updated; no change in policy statements 
04/24/09 Replace policy  Policy updated with literature review; reference numbers 12-14 added. Policy statements unchanged
07/09/09 Replace policy Policy updated with literature review; reference numbers 15 and 16 added. Policy statements unchanged.
12/09/10 Replace policy Policy updated with literature review; Rationale section rewritten; policy statement and Policy Guidelines reorganized by moving detail from Policy Guidelines to policy statements; criteria related to prior malignancy revised. Reference numbers 1-3, 6, and 8-12 added; reference numbers 13 and 20 updated.
12/08/11 Replace policy Policy updated with literature review. “Not medically necessary” policy statement on absolute contraindications removed. 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.
12/13/12 Replace Policy
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.