What insurance policy changes affect code T86.819?

There are 6 tracked policy changes affecting code T86.819, including updates from Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code T86.819?

Payers that have issued tracked updates for code T86.819 include: Aetna.

How do I get notified when code T86.819 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code T86.819. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code T86.819?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

PAYER POLICY CHANGES

T86.819 Insurance Policy Changes

ICD-10 T86.819 is officially defined as "Unspecified complication of lung transplant." code T86.819 is referenced in 6 tracked payer policy changes from Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code T86.819 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 6, 2026Medium impact
Lung Transplantation (CPB 0598, reviewed 2026-09-08)
Aetna considers lung transplantation medically necessary for qualifying conditions including cystic fibrosis, emphysema and alpha-1-antitrypsin deficiency, Eisenmenger's complex, primary pulmonary hypertension, pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis with end-stage pulmonary disease, bronchopulmonary dysplasia, and graft-versus-host disease or failed primary lung graft, when the member meets the transplanting institution's selection criteria or, without those criteria, the general and disease-specific criteria in the policy. Cystic fibrosis requires at least 2 listed signs of clinical deterioration, such as decreasing FEV1, FEV1 less than 30% predicted, or recurrent massive hemoptysis, and emphysema requires both hospitalization for COPD exacerbation with hypercapnia in the preceding year and a BODE index of 7 or above. Lung transplantation is considered not medically necessary for malignancy involving the lung, multi-system disease, refractory uncontrolled hypertension, other effective treatments being available, and smoking without 6 months of abstinence.
Aetna · Identified Oct 4, 2026Medium impact
Home/Ambulatory Spirometry (CPB 0572, reviewed 2026-09-01)
Aetna's Clinical Policy Bulletin 0572 on home and ambulatory spirometry was last reviewed 09/01/2026. Aetna considers home spirometry and telespirometry medically necessary for lung transplant recipients, and experimental, investigational or unproven for asthma, cystic fibrosis, idiopathic pulmonary fibrosis, interstitial lung disease and other chronic pulmonary disorders such as emphysema. Spirometry Holter is also considered experimental, investigational or unproven for managing asthma, and CPT 94014, 94015 and 94016 and HCPCS E0487 are covered when selection criteria are met.
Aetna · Identified Oct 4, 2026Medium impact
Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation (CPB 0599, reviewed 2026-09-18)
Autologous skeletal myoblast transplantation, intra-coronary and intra-myocardial autologous bone marrow cell transplantation, and intra-arterial or intra-muscular autologous mononuclear bone marrow cell transplantation are considered experimental, investigational, or unproven because effectiveness has not been established. Autologous or allogeneic bone marrow-derived mesenchymal stem cell transplantation is likewise considered experimental, investigational, or unproven for conditions including acute myocardial infarction, diabetes, multiple sclerosis, knee osteoarthritis, spinal cord injury, rheumatoid arthritis, Crohn's disease, and peripheral nerve repair. CPT codes 0263T, 0264T, 0265T, 38240, and 38241 and HCPCS code C9782 are listed as not covered for the listed indications, and the ICD-10 codes for those indications are listed as not covered for these services.
Aetna · Identified Oct 4, 2026Medium impact
Heart-Lung Transplantation (CPB 0597, reviewed 2026-09-08)
Aetna considers heart-lung transplantation medically necessary for persons with severe refractory heart failure plus either end-stage lung disease or irreversible pulmonary hypertension, when the selection criteria are met and no absolute contraindications are present. Examples of qualifying conditions include COPD with severe heart failure, cystic fibrosis with severe heart failure, congenital heart disease with pulmonary hypertension that is not amenable to lung transplantation and repair by standard cardiac surgery, and Eisenmenger's complex with irreversible pulmonary hypertension and severe heart failure. Heart-lung transplantation is considered not medically necessary where lung transplantation alone will restore right ventricular function.
Aetna · Identified Aug 18, 2026Medium impact
Home/Ambulatory Spirometry (CPB 0572, reviewed 2025-08-26)
Aetna considers home spirometry and telespirometry medically necessary for lung transplant recipients. It considers them experimental, investigational or unproven for asthma, cystic fibrosis, idiopathic pulmonary fibrosis, interstitial lung disease and other chronic pulmonary diseases such as emphysema. CPT 94014, 94015 and 94016 and HCPCS E0487 are covered only if the selection criteria are met.
Aetna · Identified Aug 17, 2026Medium impact
Heart-Lung Transplantation (CPB 0597, reviewed 2025-12-02)
Aetna considers heart-lung transplantation medically necessary for persons with severe refractory heart failure plus either end-stage lung disease or irreversible pulmonary hypertension, when the selection criteria are met and no absolute contraindications are present. Heart-lung transplantation is considered not medically necessary where lung transplantation alone will restore right ventricular function, and every attempt should be made to preserve the heart. The member must meet the transplanting institution's selection criteria, and in the absence of those criteria, Aetna's listed criteria apply.

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Lung Transplantation (CPB 0598, reviewed 2026-09-08)

Home/Ambulatory Spirometry (CPB 0572, reviewed 2026-09-01)

Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation (CPB 0599, reviewed 2026-09-18)

Heart-Lung Transplantation (CPB 0597, reviewed 2026-09-08)

Home/Ambulatory Spirometry (CPB 0572, reviewed 2025-08-26)

Heart-Lung Transplantation (CPB 0597, reviewed 2025-12-02)

What insurance policy changes affect code T86.819?

Which payers have updated policy for code T86.819?

How do I get notified when code T86.819 policy changes?

Why do payers change policies for code T86.819?