Read Microsoft Word - LungTransplantation,SingleOrDouble-TRP006-040208M.doc text version

Healthcare Operations Utilization Management Protocol

Lung Transplantation, Single or Double TRP006

Approved for Commercial, Medicare and Medicaid Certificate of Coverage must be reviewed to determine transplant benefits

For Sierra Health Option products please review plan documents prior to issuing a determination

CPT: 32851-32854

Description: Lung transplantation is a surgical procedure in which a patient's diseased lungs are partially or totally replaced by lungs which come from a donor. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary patients. Covered Indications: The following requirements must be met: 1. Each member's certificate of coverage must be reviewed to determine transplant benefits (i.e. organ procurement, donor testing, transportation, home health, follow-up care, etc.). 2. Transplant must be done at a contracted facility to be considered in plan. 3. Age may be a factor for lung/double lung transplantation at some facilities. 4. The primary criteria for lung transplantation include: a. Patient must have irreversible, progressively disabling, end-stage pulmonary or cardiopulmonary disease. The prognosis otherwise must be good for both survival and rehabilitation. b. All medical and surgical therapies that might be expected to yield both short and long-term survival comparable to that of transplantation must have been tried or considered. c. Chronic obstructive lung disease causing pulmonary or cardiopulmonary failure (e.g., COPD, emphysema, alpha 1 Antitrypsin Deficiency). d. Septic lung disease causing pulmonary or cardiopulmonary failure (e.g., cystic fibrosis). e. Fibrotic lung disease causing pulmonary or cardiopulmonary failure (e.g., pulmonary fibrosis). f. Vascular lung disease causing pulmonary or cardiopulmonary failure (e.g., pulmonary hypertension). g. Interstitial lung disease causing pulmonary or cardiopulmonary failure (e.g., idiopathic pulmonary fibrosis, drug or toxin induced lung disease, sarcoidosis, scleroderma, Eisenmenger's Syndrome). 5. For patients with bronchiectasis, chronic bronchitis or cystic fibrosis, single lung transplantation is contraindicated, but the patient should be considered for a double lung transplant. 6. Other factors are examined closely in assessing a potential recipient for lung transplantation. These factors have been found to have an adverse affect on post-transplant survival but alone are not absolute contraindications. a. Hepatic dysfunction b. Renal dysfunction c. Morbid obesity d. Lack of supportive social environment with a history of non-compliance with medical care e. Active peptic ulcer disease and/or active diverticulitis f. Inability to wean prednisone to 20 mgm or less per day g. Asymptomatic cerebral or peripheral vascular disease. Non-Covered Indications: Transplantation is not covered for members that do not have transplant benefits as defined in the Certificate of Coverage and benefit plan. Contraindications: Lung transplantation is contraindicated for patients with the following conditions: 1. Cachexia 2. Smoking in the last six months 3. Positive HIV * These protocols are to be used as guidelines in the decision-making process and do not represent standards of care of any individual patient. They are proprietary documents and may not be copied or distributed without express permission.

1

Healthcare Operations Utilization Management Protocol

Lung Transplantation, Single or Double

TRP 006

4. 5. 6. 7. 8. 9.

Active malignancy Coronary artery disease or left ventricular dysfunction requiring active treatment Currently on mechanical ventilation Extrapulmonary site of infection because of the probability of recrudescence once immunosuppression is instituted. Malignancy treated in the last year or remission less than one year Single lung transplantation for patients with bronchiectasis, chronic bronchitis or cystic fibrosis

Review History: Issued: 10/21/99 Revised: 4/19/07 Corporate Medical Affairs Committee Approval Dates: 9/16/04, 7/21/05, 9/21/06, 4/19/07, 4/17/08 Care Management Quality Improvement Sub Committee Approval Dates: 10/25/01, 06/20/02, 03/27/03 References: Hayes Medical Technology Directory, HCFA, 1991 Federal Register, published April 12, 1991. November 28, 1997. News Bulletin. Lung transplantation, single or double, Medicare B #138, October 1995. Operational Policy Letter #17. Department of health & human services HCFA, Medicare Managed Care March 17, 1995.

* These protocols are to be used as guidelines in the decision-making process and do not represent standards of care of any individual patient. They are proprietary documents and may not be copied or distributed without express permission.

2

Information

Microsoft Word - LungTransplantation,SingleOrDouble-TRP006-040208M.doc

2 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1102816


You might also be interested in

BETA
D:\_abs\ers2008\E.DVI
Pneumologie
DocHdl1tmpTarget