CommercialCoverageMedium impact
Heart Transplantation (CPB 0586, reviewed 2026-03-13)
Aetna·Cardiology, Cardiothoracic Surgery, Transplant Surgery +1 more·Medical Policy
Effective date
Mar 13, 2026
We identified it
Aug 17, 2026
Summary
Aetna has updated its Heart Transplantation policy (CPB 0586) effective 2026-03-13. This policy clarifies medical necessity criteria for heart transplantation, defines specific selection criteria and contraindications, establishes coverage for total artificial hearts as bridge therapy only, and designates multiple emerging rejection monitoring tests as experimental/unproven. Billing teams must ensure prior authorization processes align with these updated eligibility requirements and exclusions.
Action Required
By March 13, 2026: (1) Billing team must update prior authorization workflows in the billing system to reflect Aetna's updated heart transplantation medical necessity criteria, including the requirement that members meet NYHA Class III/IV classification (except pediatric), have >2 year life expectancy, and have no active contraindications (irreversible end-organ disease, severe pulmonary hypertension, hepatitis B antigen, AL amyloidosis, etc.). (2) Providers must document that all selection criteria are met before submitting transplant cases for authorization; add verification checklist to pre-transplant workup orders. (3) Billing team must deny or request additional documentation for claims involving: total artificial hearts used as permanent destination therapy (not bridge therapy), xenotransplantation, AlloMap testing outside the >2 months post-transplant window, or any of the experimental tests listed (Heartsbreath, cytokine gene polymorphism testing, myTAIHEART, cardiac troponin measurement for rejection, donor-derived cell-free DNA, pulmonary artery size measurement, MMDx-Heart, TransMedics Organ Care System, machine learning/AI applications, or Prospera Heart test). (4) Update denial templates to reference CPB 0586 for non-covered experimental procedures. Failure to implement these requirements will result in inappropriate claim denials and member appeals.