Medicare Advantage

Medical Policy

Title:

Solid Organ Transplantation and Procurement Cost of Organs and Tissues

Policy #:

MA11.033c

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

Solid organ transplants are considered medically necessary and, therefore, covered when performed on selected individuals who have severe diseases or irreversible organ damage and who meet the criteria established by United Network for Organ Sharing (UNOS)/Organ Procurement and Transplantation Network (OPTN) and Medicare when appropriate. The following organs are recognized as medically suitable for transplant consideration:

Heart
Heart–Lung
Intestinal (includes the esophagus, stomach, small or large intestine, or any portion of the gastrointestinal tract), and multivisceral (includes the stomach, duodenum, pancreas, liver, and intestine)
Kidney
Pancreas
Pancreas–Kidney
Liver
Liver–Kidney
Lung: Single/Double

Per the Organ Procurement and Transplant Network (OPTN), all multi-organ candidates must be registered on the waiting list for each required organ. The minimal acceptance criteria for each organ or multiorgan combinations must be met. OPTN policies may be found at: https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf.

TRANSPLANT PROGRAM REQUIREMENTS

To the extent a facility operates any transplant programs, all such programs must be Medicare certified, and each program must be an OPTN member that has been certified by the UNOS (the organization that manages the nation's organ transplant system under contract with the federal government) or its successor entity. In the event that a transplant program does not have both Medicare and UNOS certification, any transplant services or transplant-related services (including pre- and posttransplant) provided by the program are considered noncovered services, and, therefore, not eligible for reimbursement.

Additionally, please note:

Pre- and posttransplant services related to a solid organ transplant include, but are not limited to, laboratory tests and radiology studies.
Facilities performing multiorgan transplants must have a transplant program that is Medicare and UNOS certified for each organ involved, as multiorgan certification may not be available.
Pediatric transplant programs are excluded from the Medicare certification requirement for non-Medicare business.

Medicare Advantage members must have transplants performed in a Medicare-approved facility. A list of Medicare-approved facilities is available on the Centers for Medicare & Medicaid Services (CMS) Web site at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf.

COVERED TRANSPLANTS

Most Evidence of Coverage includes coverage for all of the above transplants. In the absence of explicit exclusions, the transplants listed above are available under the member's Evidence of Coverage.

MEMBER AND NONMEMBER INFORMATION

A living organ donation to a Medicare transplant recipient, by a non-Medicare insured individual is covered under the Medicare medical benefit. These services include the donor's organ acquisition and procurement and inpatient stay. The donor of an organ for the Medicare transplant recipient is covered for an unlimited number of days of care in connection with the organ removal. Follow-up examinations may be covered up to 6 months following the donation of the organ, to monitor for possible complications.

TRAVEL EXPENSES

Travel and living expenses that are associated with an out-of-area transplant center, for either the donor or the recipient, are excluded from organ transplant coverage with the following exceptions:

Reasonable transportation and reasonable accommodations out of network, for a Medicare Advantage member, who is the recipient of the organ transplant and a companion are covered and eligible for reimbursement consideration by the Company when the transplant services are not available in-network, subject to Plan authorization.
- However, if a Medicare Advantage member elects to receive transplant services out-of-network when the services are available in-network, the member is responsible for all associated travel expenses.
Travel expenses of the living donor related to the transplantation are not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

PROCUREMENT COST OF ORGAN AND TISSUE

All costs incurred during organ and tissue procurement are billed to the regional donor program. The transplant recipient's transplant hospital will then reimburse the donor program for the procurement costs. In turn, the hospital is reimbursed by the recipient's insurance company.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, solid organ transplants are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

ORGAN TRANSPLANTATION

Organ and tissue transplantation is a process by which the organ and tissue are excised from a live or cadaveric donor, then implanted in a recipient. Transplants are intended to prolong survival and improve the function of individuals with severe diseases or irreversible organ damage.

The term "solid organ" is used to distinguish bone marrow, stem cells, and similar tissues from partial and complete organs.

Solid organs for transplantation include the heart, lung, kidney, pancreas, liver, intestine, and stomach.

The Organ Procurement and Transplantation Network (OPTN) is the unified transplant network established by the United States Congress under the National Organ Transplant Act (NOTA) of 1984. The Act called for the network to be operated by a private, nonprofit organization under federal contract. The United Network for Organ Sharing (UNOS), based in Richmond, Virginia, administers the OPTN under contract with the Health Resources and Services Administration of the US Department of Health and Human Services.

OPTN is a unique public-private partnership that links all of the professionals involved in the donation and transplantation of organs in an effort to improve the effectiveness and efficiency of organ sharing. OPTN acts to bring equity in the national system of organ allocation and to increase the supply of donated organs available for transplantation.

Any operating transplant facility in the United States that provides transplant services must be an approved member of UNOS/OPTN. Requirements for each organ transplant are established by UNOS/OPTN through their policies and bylaws for facilities that apply for membership to the organization. Membership entails completion of the prescribed application process and satisfaction of applicable requirements in which the organization/facility has demonstrated compliance with all applicable UNOS membership criteria. The policies and bylaws set forth by OPTN include specific expectations about how members remain in compliance. If a Member is unable to demonstrate their ability to meet the applicable membership criteria at all times, the Member’s OPTN membership will be terminated by the OPTN, and the Member will no longer be able to provide transplant services. In addition, most transplant facilities also obtain Medicare certification for the organ transplants being performed.

According to the OPTN Bylaws Appendix D, the OPTN does not grant designated transplant program approval for any type of vascularized organ transplantation for which the OPTN has not established specific criteria. In order to perform vascularized organ transplantation procedures for which there are no OPTN-established criteria, including multivisceral transplants, e.g., combination liver-kidney transplant, a hospital must be a transplant hospital member and have current approval as a designated transplant program for at least one of the organ types involved in multi-visceral transplant. In the case of abdominal multivisceral organ transplants, the transplant hospital must have approval as a designated liver transplant program.

PROCUREMENT COSTS OF ORGANS AND TISSUES

The regional donor program coordinates the recovery of organs and tissues for transplant from living or cadaveric donors. The donor program is responsible for the identification and care of organ donors; organ retrieval, preservation, and transportation; and data follow-up regarding cadaveric organ donors. The reimbursement process for organ and tissue recovery is managed by the regional donor program.

References

Centers for Medicare & Medicaid Services (CMS). Approved Transplant Centers. [CMS Web site]. Revised: 02/11/2020. Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/transplantcenters. Accessed August 24, 2026.

Centers for Medicare & Medicaid Services (CMS). Hospital Conditions of Participation: Requirements for Approval and Re-Approval of Transplant Centers To Perform Organ Transplants; [CMS Web site]. Effective 6/28/2007. Updated 07/19/2017. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/TransplantFinalLawandReg.pdf. Accessed August 24, 2026.

Centers for Medicare & Medicaid Services (CMS). Transplant. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Transplant-Laws-and-Regulations.html. Accessed March 04, 2025. No longer available.

Medicare Department of Health & Human Services (DHHS) Centers for Medicare & Provider Reimbursement Manual Medicaid Services (CMS) Part 1 - Chapter 31, Organ Acquisition Payment Policy Transmittal 471. April 1, 2016. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R471pr1.pd Accessed August 24, 2026.

Organ Procurement and Transplantation Network (OPTN). [OPTN Web site]. 11/18/05. Available at: http://optn.transplant.hrsa.gov/. Accessed August 24, 2026.

United Network for Organ Sharing (UNOS). [UNOS Web site]. 2018. Available at: http://www.unos.org/. Accessed August 24, 2026.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

THE FOLLOWING CODE IS USED TO REPRESENT PHYSIOLOGICAL SUPPORT:

01990

HEART TRANSPLANT

Donor

33940, 33944

Recipient

33945

HEART-LUNG TRANSPLANT

Donor

33930, 33933

Recipient

33935

INTESTINAL TRANSPLANT

Donor

44132, 44133, 44715, 44720, 44721

Recipient

44135, 44136, 44137

KIDNEY TRANSPLANT

Donor

50300, 50320, 50323, 50325, 50327, 50328, 50329, 50547

Recipient

50340, 50360, 50365, 50370

PANCREAS TRANSPLANT

Donor

48550, 48551, 48552

Recipient

48554, 48556

LIVER TRANSPLANT

Donor

47133, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147

Recipient

47135

THE FOLLOWING CODE IS USED TO REPRESENT LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE

47399

LUNG TRANSPLANT

Donor

32850, 32855, 32856

Recipient

32851, 32852, 32853, 32854

EXPERIMENTAL/INVESTIGATIONAL

0494T, 0495T, 0496T

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

LIVER - KIDNEY TRANSPLANT

RECIPIENT
S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition

LUNG TRANSPLANT

DONOR
S2061 Donor lobectomy (lung) for transplantation, living donor

RECIPIENT
S2060 Lobar lung transplantation

MULTIVISCERAL TRANSPLANT

DONOR
S2055 Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor

RECIPIENT
S2054 Transplantation of multivisceral organs

PANCREAS - KIDNEY TRANSPLANT

RECIPIENT
S2065 Simultaneous pancreas kidney transplantation

SMALL INTESTINE AND LIVER TRANSPLANT

RECIPIENT
S2053 Transplantation of small intestine, and liver allografts

SOLID ORGAN TRANSPLANT (SINGLE OR MULTIPLE ORGANS)

RECIPIENT
S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition

THE FOLLOWING CODE IS ELIGIBLE FOR MEDICARE ADVANTAGE MEMBERS FOR REASONABLE TRANSPORTATION AND ACCOMMODATIONS

S9975 Transplant related lodging, meals and transportation, per diem

Revenue Code Number(s)

0362 Operating Room Services—Organ Transplant—Other than Kidney

0367 Operating Room Services—Kidney Transplant

0810 Acquisition of Body Components—General

0811 Acquisition of Body Components—Living Donor

0812 Acquisition of Body Components—Cadaver Donor

0813 Acquisition of Body Components—Unknown Donor

0819 Acquisition of Body Components—Other Donor

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.033c:

09/30/2026	This version of the policy will become effective 09/30/2026. This policy has been reviewed to communicate the Company's continuing position on solid organ transplantation and procurement cost of organs and tissues.
04/02/2025	This policy has been reissued in accordance with the Company's annual review process.
06/17/2024	This version of the policy will become effective 06/17/2024. This policy has been reviewed to communicate the Company's continuing position on Solid Organ Transplantation and Procurement Cost of Organs and Tissues.

Revisions From MA11.033b:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
08/09/2023	This policy has been reissued in accordance with the Company's annual review process.
10/19/2022	This policy has been reissued in accordance with the Company's annual review process.

06/16/2021	This policy has been reissued in accordance with the Company's annual review process.
11/04/2020	The policy has been reviewed and reissued to communicate the Company's continuing position on Solid Organ Transplantation and Procurement Cost of Organs and Tissues.
09/11/2019	This policy has been reissued in accordance with the Company's annual review process.
12/05/2018	The policy has been reviewed and reissued to communicate the Company's continuing position on Solid Organ Transplantation and Procurement Cost of Organs and Tissues.
01/01/2018	This policy was expanded to communicate Company's position on procurement cost of organs and tissues. The following CPT code was removed from this policy: 50380 The following code was added to this policy to represent physiological support:: 01990 The following codes were added to the policy as experimental/investigational: 0494T, 0495T, 0496T

Revisions From MA11.033a:

01/01/2016

This version of the policy will become effective 01/01/2016.

The following: CPT code has been deleted from this policy and is being replaced with the following Not Otherwise Classified (NOC) code:

Deleted: 47136
Replaced with: 47399

Revisions From MA11.033:

02/04/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on solid organ transplants.
01/01/2015	This is a new policy.

Version Effective Date:

6/17/2024

Version Issued Date: