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AetnaAll Plans · Coverage · Medical Policy · Cardiology, Cardiothoracic Surgery, Transplant SurgeryMedium impact

Heart Transplantation (CPB 0586, reviewed 2026-03-13)

Effective date
Not stated in the notice
Identified
Aug 17, 2026

Summary

Aetna considers heart transplantation medically necessary when the member meets the transplanting institution's protocol eligibility criteria. Off protocol, all listed selection criteria must be met, including NYHA class III or IV heart failure (not required for pediatric members), life expectancy greater than 2 years in the absence of cardiovascular disease, and no absolute contraindications. The policy also covers the FDA-approved total artificial heart as a bridge to transplant for transplant-eligible members at imminent risk of death, covers AlloMap for rejection monitoring more than 2 months after transplant, and covers ex vivo heart perfusion for preservation and transport of the donor heart, while listing the total artificial heart as destination therapy and several rejection and graft tests as experimental, investigational, or unproven.

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What to do

Action · 5 steps
01Billing team: For heart transplant services (CPT 33945), confirm the member meets the transplanting institution's protocol eligibility criteria or, off protocol, all listed selection criteria.
02Heart transplant is considered not medically necessary for members with any listed contraindication, including irreversible end-organ disease, severe pulmonary hypertension with irreversibly high pulmonary vascular resistance, a recent intracranial cerebrovascular event with significant persistent deficit, bleeding peptic ulcer, hepatitis B antigen, immediately life-threatening neuromuscular disorders, HIV/AIDS with CD4 count less than 200 cells/mm3, or AL amyloidosis unless curative therapy has been performed or is planned.
03Bill AlloMap (CPT 81595) as medically necessary only for rejection monitoring more than 2 months after heart transplant; the appendix gives the recommended surveillance frequency (every 2 to 4 weeks from 2 to 6 months, every 2 months from 6 to 12 months, every 3 months from 12 to 24 months, every 6 months from 24 to 60 months, and every 12 months after 60 months) and states that testing is not routinely indicated beyond 5 years.
04Services the policy lists as experimental, investigational, or unproven are not considered medically necessary under this policy: Heartsbreath test, myTAIHEART, MMDx-Heart, Prospera Heart, donor-derived cell-free DNA tests (Allosure, Prospera) for rejection monitoring, troponin measurement for diagnosis of acute cellular rejection, pulmonary artery size measurement, cytokine gene polymorphism testing, immune repertoire sequencing, cardiac xenotransplantation, and machine learning or artificial intelligence in cardiac transplantation.
05A total artificial heart used as permanent treatment (destination therapy) is considered experimental, investigational, or unproven, while an FDA-approved total artificial heart is medically necessary as a bridge to transplant for transplant-eligible members at imminent risk of death (NYHA Class IV) from biventricular failure who are awaiting heart transplantation.

Codes mentioned

339273392833929339353394033945815957127584484L8698Z94.1

Original notice

Heart Transplantation (CPB 0586, reviewed 2026-03-13)
aetna.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Aetna policiesCardiologyCardiothoracic SurgeryTransplant SurgeryCode 33927Code 33928Code 33929Code 33935Code 33940Code 33945Code 81595Code 71275Code 84484Code L8698Code Z94.1

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