Summary
Excellus BlueCross BlueShield policy 7.02.06 considers heart transplantation medically appropriate for select adults with end-stage heart disease that has not responded to other medical or surgical therapy, when recipient selection criteria are met. Acceptable heart indications include hemodynamic compromise with maximal oxygen consumption below 10 ml/kg/min, refractory cardiogenic shock, or dependence on intravenous inotropic support; severe ischemia not amenable to bypass surgery or angioplasty; and recurrent symptomatic ventricular arrhythmias refractory to accepted therapy. Heart-lung transplantation is considered medically appropriate for carefully selected individuals with end-stage cardiac and pulmonary disease, such as Eisenmenger complex, cystic fibrosis with severe heart failure, or COPD with heart failure. Pre-transplant evaluation documentation should include clinical, psycho-social, performance status, oral health, laboratory, cardiac, pulmonary and age-appropriate screening information, with a rationale where testing is not performed. Transplant reauthorization is required annually while on the waiting list. The current effective date is July 16, 2026, and the annual review states policy intent is unchanged.
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