ICD-10 Z76.82 is officially defined as "Awaiting organ transplant status." code Z76.82 is referenced in 21 tracked payer policy changes from Health Net, Excellus BlueCross BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z76.82 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Health Net updated 16 medical policies with new prior authorization requirements, billing code changes, and coverage criteria changes for Q2 2021. Key changes include new CPT codes for ADHD testing that are now not medically necessary, updated HCPCS codes for skin substitutes, and revised criteria for multiple procedures including gender affirming care and spinal cord stimulation.
Health Net updated multiple medical policies for Q2 2021, including new policies for TMS treatment, EMG/nerve studies, and nasal valve repair, plus significant updates to ADHD testing codes, gender affirming procedures, and pain management nerve blocks. Multiple CPT, HCPCS, and ICD-10 codes were added, removed, or modified across various specialties.
CalViva Health (Medi-Cal) updated multiple medical policies for Q2 2021, affecting prior authorization requirements, billing codes, and coverage criteria across numerous specialties. Key changes include updated CPT codes for ADHD testing, nerve studies, and spinal procedures, plus revised criteria for gender-affirming procedures, pain management, and wound care.
Excellus BlueCross BlueShield policy 7.01.114 covers ventricular assist devices (VADs) and total artificial hearts (TAH) for listed indications. FDA-approved VADs are considered medically appropriate as a bridge to transplant for individuals who meet all listed criteria, including approval as a heart transplant candidate by an approved heart transplant center, imminent risk of dying before donor heart procurement, optimal inotropic support, and an intra-aortic balloon pump unless contraindicated. VADs are also considered appropriate as a bridge to recovery and as destination therapy for adults who meet all listed criteria, such as NYHA Class III or IV heart failure, left ventricular ejection fraction of 25% or less, and inotrope dependence or a cardiac index below 2.2 liters/min/m2. Percutaneous VADs are considered medically necessary for listed indications, including high-risk PCI and short-term circulatory support in cardiogenic shock. A TAH is considered medically appropriate as a bridge to transplant, while a TAH as destination therapy is considered investigational.
Excellus BlueCross BlueShield policy 7.01.69 considers transarterial radioembolization (TARE) with yttrium-90 microspheres medically necessary for unresectable or medically inoperable hepatocellular carcinoma, as a bridge to transplant for patients who meet liver transplant criteria and are waiting, for intrahepatic cholangiocarcinoma, and for unresectable metastatic hepatic tumors that meet the listed criteria (neuroendocrine tumors, colorectal, breast, and melanoma). A second TARE is considered medically necessary for a new, progressive tumor after a satisfactory response to an initial TARE, and a third TARE is considered not medically necessary. The version effective February 19, 2026 is an annual review with policy intent unchanged, following a 02/20/25 revision that added statements for primary intrahepatic cholangiocarcinoma and for metastatic hepatic tumors related to cutaneous melanoma.
Aetna considers orthotopic liver transplantation medically necessary for members with end-stage liver disease from the listed conditions who meet the criteria below. Adolescents 12 years of age or older and adults qualify with a MELD score greater than 10, approval by the UNOS Regional Review Board, or when they meet the transplant institution's selection criteria, and children under 12 qualify when they meet the transplanting institution's selection criteria. Liver transplantation is not medically necessary for absolute contraindications including active sepsis outside the biliary tract, inability to adhere to the transplant regimen (including homelessness, active substance abuse, and unstable psychiatric disease or psychosocial problem), presence of other effective treatments or surgical options, and significant organ system failure other than kidney, liver or small bowel.
Aetna Clinical Policy Bulletin 0654 covers ventricular assist devices (VADs) and sets the criteria under which Aetna considers them medically necessary. A VAD is medically necessary as a bridge to transplant when the device has FDA approval for that indication and the member is awaiting heart transplantation. A VAD for destination therapy requires NYHA Class IV end-stage ventricular heart failure, a member who is not a candidate for heart transplant, an LVEF less than 25%, and the medical management and peak oxygen consumption criteria listed in the policy. Percutaneous VADs such as the TandemHeart and Impella are medically necessary for short-term circulatory support in cardiogenic shock and for listed high-risk PCI situations, and VADs are considered experimental, investigational, or unproven for all other indications.
Aetna considers percutaneous ethanol injection (PEI) medically necessary for hepatocellular carcinoma (HCC) without extra-hepatic spread and for neuroendocrine cancers involving the liver. Chemoembolization is medically necessary for neuroendocrine cancers involving the liver, unresectable primary HCC, liver-only metastasis from uveal melanoma, and pre-operative hepatic artery chemoembolization followed by orthotopic liver transplantation for HCC. Intra-hepatic microspheres (TheraSphere, SIR-Spheres, also known as trans-arterial radio-embolization) are medically necessary for neuroendocrine cancers involving the liver, unresectable primary HCC, unresectable liver tumors from primary colorectal cancer, unresectable and chemo-refractory intra-hepatic cholangiocarcinoma with liver metastases only, and pre-operative use as a bridge to orthotopic liver transplantation for HCC. Intra-hepatic chemotherapy is medically necessary for members with liver metastases from colorectal cancer. Many other uses are listed as experimental, investigational or unproven, including chemoembolization for palliative treatment of liver metastases from non-neuroendocrine primaries, PEI for liver neoplasms when the criteria above are not met, combined electrochemotherapy and immunotherapy for HCC, the TriNav Infusion System, the TheraBionic P1 System, and degradable starch microsphere chemoembolization for HCC.
Aetna considers ECMO medically necessary for neonates who meet all of these criteria: a listed diagnosis (congenital diaphragmatic hernia, hyaline membrane disease, meconium aspiration, persistent fetal circulation, possible cardiac anomaly, refractory neonatal septic shock, respiratory distress syndrome, or uncontrollable air leak), gestational age of at least 34 weeks, birth weight of 2,000 grams or greater, and age less than 10 days (preferably less than 7 days). For children and adults, ECMO and extracorporeal life support are considered medically necessary for listed diagnoses when the risk of death is very high despite optimal conventional therapy, including ARDS, a short-term bridge to heart, liver, lung or heart-lung transplantation or to durable mechanical circulatory support, support following heart surgery to ease the transition from cardiopulmonary bypass to ventilation, non-necrotizing pneumonias, primary graft failure after transplant, pulmonary contusion, refractory pediatric septic shock, smoke inhalation injury, and other reversible causes of respiratory or cardiac failure unresponsive to all other measures. Aetna considers ECMO experimental, investigational, or unproven for all other indications, including acute coronary syndromes, acute massive pulmonary embolism, burns not accompanied by ARDS, cardiogenic shock or smoke inhalation injury, sepsis other than refractory pediatric septic shock, refractory status asthmaticus, tuberculosis, and drug overdose.
Aetna considers donor lymphocyte infusion medically necessary for persons who have had a prior medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Several uses are considered experimental, investigational, or unproven, including GCSF-stimulated donor lymphocyte infusions for relapsed disease, intrathecal donor lymphocyte infusion, modified donor lymphocytes, reduced-dose infusion for Epstein-Barr virus-related post-transplant lymphoproliferative disease, pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes for solid organ transplant, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved chimeric antigen receptor therapy, which is addressed in CPB 0920 and CPB 0924.
Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. Where no institution criteria apply, the member must complete an evaluation and be accepted by the kidney transplant committee, meet the transplanting institution's protocol age criteria, have no malignancy except the listed exceptions, and meet the policy's infection, cardiovascular, pulmonary, hepatic and severity-of-disease criteria. Aetna considers belatacept (Nulojix) medically necessary for preventing acute rejection in kidney transplant recipients who are sero-positive for Epstein-Barr virus, and equine anti-thymocyte globulin (Atgam) medically necessary for prophylaxis or treatment of allograft rejection in renal transplantation in combination with conventional therapy, and for moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation, while gene microarray, donor-derived cell-free DNA, urinary biomarker, TruGraf and AI/ML graft survival tests are experimental, investigational, or unproven for the indications listed.
Aetna considers an FDA-approved ventricular assist device medically necessary as a bridge to transplant when the device has FDA approval for that indication, and as destination therapy when all of the listed criteria are met: NYHA Class IV end-stage heart failure, not a candidate for heart transplant, failure to respond to optimal medical management for at least 45 of the last 60 days (or balloon pump dependence for 7 days, or IV inotrope dependence for 14 days), LVEF less than 25%, and peak oxygen consumption less than or equal to 14 mL/kg/min. Percutaneous VADs such as the TandemHeart and the Impella are medically necessary for short-term circulatory support in cardiogenic shock and as an adjunct to high-risk PCI in the listed scenarios, and short-term LVADs, RVADs or BiVADs such as the CentriMag are medically necessary for up to 30 days in post-cardiotomy or refractory acute cardiogenic shock when the member is willing and able to be treated with heparin or an appropriate alternative anticoagulant. VADs are considered experimental, investigational or unproven for all other indications, including concomitant mitral valve surgery with LVAD implantation for mitral regurgitation, pVADs during ablation of ventricular tachycardia, implantable aortic counterpulsation ventricular assist systems, and use of mesenchymal precursor cells as adjunctive therapy in VAD recipients.
Aetna considers transjugular intrahepatic portosystemic shunt (TIPSS) medically necessary for bleeding gastric, esophageal or ectopic varices, moderate Budd-Chiari syndrome that has failed to respond to anticoagulation, portal hypertensive gastropathy with recurrent bleeding despite beta-blockers, severe refractory ascites in people who are intolerant of repeated large volume paracentesis, and refractory hepatic hydrothorax, when the member meets the selection criteria in the Appendix. TIPSS is experimental, investigational, or unproven for all other indications, including initial therapy for acute variceal hemorrhage, prophylaxis of variceal hemorrhage, and hepatorenal syndrome.
Aetna considers percutaneous ethanol injection, chemoembolization, intra-hepatic chemotherapy and intra-hepatic microspheres (also called TARE) medically necessary for listed liver indications. These include unresectable primary hepatocellular carcinoma (HCC), neuroendocrine tumors involving the liver, liver-only metastasis from uveal melanoma, unresectable liver tumors from colorectal cancer, and pre-operative use before liver transplantation for HCC. The policy considers many other uses experimental, investigational or unproven, including chemoembolization for liver metastases from non-neuroendocrine primaries, combined radiofrequency ablation and percutaneous ethanol injection for HCC, drug-eluting beads for liver metastases from colorectal cancer, the TriNav Infusion System and the TheraBionic P1 System.
Aetna considers ECMO medically necessary for neonates who have one of the listed diagnoses, including congenital diaphragmatic hernia, meconium aspiration, persistent fetal circulation, respiratory distress syndrome, or uncontrollable air leak, when the neonate has a gestational age of at least 34 weeks, a birth weight of 2,000 grams or greater, and an age under 10 days (preferably under 7 days). For children and adults, ECMO and ECLS are considered medically necessary when the risk of death is very high despite optimal conventional therapy, for indications such as ARDS, a short-term bridge to heart, liver, lung or heart-lung transplantation, a short-term bridge to durable mechanical circulatory support, and smoke inhalation injury. Aetna considers ECMO experimental, investigational, or unproven for all other indications, including COVID-19 in persons not meeting the medical necessity criteria, sepsis other than refractory pediatric septic shock, acute coronary syndromes, and tuberculosis.
Aetna considers cardiopulmonary exercise testing (CPET, CPT 94621) medically necessary for listed conditions after standard testing, including echocardiography, pulmonary function testing with diffusion capacity, and oxygen desaturation measured on the 6-minute walk test. The listed conditions include post-operative evaluation of chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy, developing exercise prescriptions for cardiac or pulmonary rehabilitation, evaluating exercise capacity and response to therapy in chronic heart failure patients considered for heart transplantation or other advanced therapies, and evaluating post-acute sequelae of COVID-19 (Long COVID). CPET is considered experimental, investigational or unproven as a screening exercise test, as a routine pre-operative assessment, and as a first-line diagnostic test for possible cardiac or pulmonary pathology.
Aetna's Cardioverter-Defibrillators policy (CPB 0585, last review 04/22/2026) covers FDA-approved implantable cardioverter-defibrillators for members with listed indications, including spontaneously occurring ventricular fibrillation or sustained ventricular tachycardia not associated with acute myocardial infarction, and ischemic or non-ischemic dilated cardiomyopathy with NYHA class II or III heart failure and an LVEF of 35% or less on optimal medical therapy. Extravascular and subcutaneous defibrillators and wearable or non-wearable cardioverter-defibrillators are covered only under the criteria stated, while ICDs with hemodynamic monitoring, use in persons with left ventricular assist devices, and N-terminal pro-B type natriuretic peptide testing for prognosis of ICD implantation are listed as experimental, investigational or unproven.
Aetna considers quantitative pupillometry and pupillography experimental, investigational, or unproven for all indications, including the following: intracranial pressure monitoring, pain assessment, early concussion assessment, Parkinson disease, Alzheimer's disease, heart failure, depression, prediction of outcome after cardiac arrest, and glaucoma, because its effectiveness has not been established. Chromatic pupillography is considered experimental, investigational, or unproven for detecting glaucoma, Leber congenital amaurosis, optic nerve diseases, and retinitis pigmentosa, and for evaluating Gaucher disease and hemianopia. CPT 95919 (quantitative pupillometry with physician or other qualified health care professional interpretation and report) is listed as not covered for the indications in this policy.
Aetna considers donor lymphocyte infusion (DLI) medically necessary for persons who have had a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation. Aetna considers these uses experimental, investigational, or unproven: GCSF-stimulated DLI for relapsed disease after allogeneic hematopoietic cell transplantation, intrathecal DLI, modified donor lymphocytes (such as depleted, expanded, T-cell depleted, CAR-modified or genetically modified cells), pre-transplant infusion of extracorporeal photochemotherapy-treated donor lymphocytes to prevent graft rejection after solid organ transplantation, reduced-dose DLI for Epstein-Barr virus-related post-transplant lymphoproliferative disease, and donor lymphocyte-derived natural killer cells for melanoma. The policy does not apply to FDA-approved CAR T therapy, which involves modification of autologous lymphocytes.
Aetna considers entry into a medically supervised outpatient pulmonary rehabilitation program medically necessary when the member has a chronic pulmonary disease or another condition that affects pulmonary function, dyspnea at rest or with exertion, reduced exercise tolerance that restricts activities of daily living or work, symptoms that persist despite appropriate medical management, and a moderate to severe functional pulmonary disability. That disability is shown either by a maximal exercise stress test with VO2max of 20 ml/kg/min or less (about 5 METS) or by FEV1, FVC, FEV1/FVC, or DLCO below 60 % of predicted, and the member must be physically able, motivated, and willing to participate. A typical course extends for up to 6 weeks or 36 hours of therapy. Repeat programs are considered not medically necessary, except in connection with lung transplantation or lung volume reduction surgery, and routine, maintenance, or non-skilled care is considered not medically necessary. Pulmonary rehabilitation is considered experimental, investigational, or unproven for all other indications.
Aetna considers daratumumab (Darzalex) and daratumumab and hyaluronidase-fihj (Darzalex Faspro) medically necessary for the listed indications, including multiple myeloma regimens, systemic light chain amyloidosis, HIV-related plasmablastic lymphoma used with dose-adjusted EPOCH, relapsed or refractory T-cell acute lymphoblastic leukemia, POEMS syndrome, plasma cell-related monoclonal immunoglobulin deposition disease, and plasma cell-related monoclonal gammopathy of renal significance, when each listed criteria set is met. Continuation of therapy is considered medically necessary on reauthorization when there is no evidence of unacceptable toxicity or disease progression on the current regimen. Aetna considers all other indications experimental, investigational, or unproven.
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