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Organ transplantation involves the excision of an organ from a live or cadaveric donor and implantation of the organ into a recipient patient. Transplantation is intended to prolong survival and improve function in patients with severe disease or irreversible organ damage. 

Definitions

Cholangiocarcinoma: Bile duct carcinoma, which may be generally categorized as intrahepatic, extrahepatic (hilar or perihilar), and distal extrahepatic.

Multivisceral: More than one organ.

Steatohepatitis: A type of liver disease, characterized by inflammation and accumulation of fat in the liver.

I.  The following organ transplant procedures may be considered MEDICALLY NECESSARY AND APPROPRIATE when the following criteria are met:

• Kidney
  • Kidney transplantation (with either a living or cadaver donor) for patients with end-stage renal disease who meet patient selection criteria established by the Organ Procurement and Transplantation Network (OPTN) and the United Network of Organ Sharing (UNOS)
  • Kidney retransplantation after a failed primary kidney transplant in patients who meet criteria for a kidney transplantation
• Heart
  • Heart transplantation for adult or pediatric patients with end-stage heart failure who meet patient selection criteria established by the Organ Procurement and Transplantation Network (OPTN) and the United Network of Organ Sharing (UNOS)
  • Heart retransplantation after a failed primary heart transplant in patients who meet criteria for heart transplantation
• Heart/Lung
  • Heart/lung transplantation for patients with end-stage cardiac and pulmonary disease who meet patient selection criteria established by the Organ Procurement and Transplantation Network (OPTN) and the United Network of Organ Sharing (UNOS)
  • Heart/lung retransplantation after a failed primary heart/lung transplantation in patients who meet criteria for heart/lung transplantation
• Lung and Lobar Lung
  • Lung and lobar lung transplantation for patients with irreversible, progressively disabling, end-stage pulmonary disease who  meet patient selection criteria established by the Organ Procurement and Transplantation Network (OPTN) and the United Network of Organ Sharing (UNOS)
  • Lung or lobar lung retransplantation after a failed primary lung or lobar lung transplant in patients who meet criteria for lung transplantation
• Isolated Small Bowel
• Initial isolated small bowel transplantation for patients who meet ALL of the following:
• Intestinal failure, characterized by loss of absorption and the inability to maintain protein, energy, fluid, electrolyte, or micronutrient balance; AND
• Established, long-term dependency on total parenteral nutrition (TPN); AND
• One of the following:
  1. Patient is developing or has developed severe complications due to TPN including but not limited to:
     • Multiple and prolonged hospitalizations to treat TPN-related complications (e.g., repeated episodes of catheter-related sepsis); OR
     • Development of progressive liver failure; OR
     • Thrombosis of the major central venous channels; jugular, subclavian, and femoral veins; OR
  2. Inability to maintain venous access for TPN.
• Isolated small bowel retransplantation after a failed primary small bowel transplant in patients who meet criteria for small bowel transplantation.
• Small Bowel/Liver and Multivisceral
  • Small bowel/liver or multivisceral transplantation for patients who meet the following criteria:
    • Intestinal failure characterized by loss of absorption and the inability to maintain protein, energy, fluid, electrolyte, or micronutrient balance; AND
    • Established long-term dependency on total parenteral nutrition (TPN) and evidence of impending end-stage liver failure
  • Small bowel/liver retransplantation or multivisceral retransplantation after a failed primary small bowel/liver transplant or multivisceral transplant in patients who meet criteria for small bowel/liver or multivisceral transplantation.
• Allogeneic Pancreas
  • Combined pancreas-kidney transplantation in diabetic patients with end-stage renal disease
  • Pancreas transplantation after a prior kidney transplantation in patients with insulin-dependent diabetes
  • Pancreas transplantation alone in patients with severely disabling and potentially life-threatening complications due to hypoglycemia unawareness or labile diabetes that persists despite optimal medical management
  • Pancreas retransplantation after a failed primary pancreas transplantation in patients who meet criteria for pancreas transplantation
• Liver
  • Liver transplantation, with either a cadaver or living donor, in patients with end-stage liver failure due to irreversible damage to the liver. Conditions causing end-stage liver disease include, but are not limited to, the following:
    • Hepatocellular disease
      1. Alcoholic cirrhosis
      2. Viral hepatitis (A, B, C);
      3. Autoimmune hepatitis;
      4. Alpha-1 antitrypsin deficiency;
      5. Hemochromatosis;
      6. Non-alcoholic steatohepatitis (NASH);
      7. Protoporphyria;
      8. Wilson's disease
    • Cholestatic liver disease
      1. Primary biliary cirrhosis;
      2. Primary sclerosing cholangitis with development of secondary biliary cirrhosis;
      3. Biliary atresia
    • Vascular disease
      1. Budd-Chiari syndrome
    • Primary hepatocellular carcinoma
    • Inborn errors of metabolism
    • Trauma and toxic reactions
    • Polycystic disease of the liver in patients who have massive hepatomegaly causing obstruction or functional impairment of other organs
    • Familial amyloid polyneuropathy
    • Hilar cholangiocarcinoma that cannot be separately resected
    • Nonmetastatic hepatoblastoma in pediatric patients
  • Liver retransplantation in patients with the following indications:
    • Primary graft non-function
    • Hepatic artery thrombosis
    • Chronic rejection
    • Ischemic-type biliary lesions
    • Recurrent non-neoplastic disease causing late graft failure
• Liver/Kidney
  • Combined liver-kidney transplantation for patients who meet the criteria for liver transplantation and have advanced irreversible kidney disease

II.  All other indications for organ transplantation are considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes. Those indications include, but are not limited to:

• Liver transplantation
  • Intrahepatic cholangiocarcinoma
  • Extrahepatic malignancy, other than hilar cholangiocarcinoma that cannot be separately resected
  • Hepatocellular carcinoma extending beyond the liver
  • Neuroendocrine tumors metastatic to the liver
  • Patients with ongoing alcohol and/or drug abuse (Abstinence defined according to transplant program protocol)

Documentation Submission:

Link to Transplant Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2019-12/X16519R04_Transplant%20Request%20Form.pdf