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Transplant Authorization Code List

December 2013

Authorization is required for the following transplant procedures: stem cell, heart-lung, lung, pancreas, pancreas-kidney, liver, intestine, intestine-liver, and autologous pancreatic islet cell transplant (after pancreatectomy).

Transplant prior authorization request must be submitted to Authorization Medical Review Agent by the physician rather than the transplant facility. The transplant facility may request documentation of the prior authorization approval from the physician's office or by calling the MHCP Provider Call Center at 651-431-2700 or 1-800-366-5411.

The medical report must include the following information:

  • • Diagnosis, including ICD diagnosis code
  • • Proposed treatment
  • • Sufficient, pertinent information
  • If a transplant is to be performed out-of-state, the provider must obtain authorization prior to the service being rendered. Refer to the instructions in the MHCP Authorization policy for out-of-state services. If the procedure will be performed in an out-of-state hospital the prior authorization request must include evidence that the hospital meets the requirements of Medicare, UNOS, and Foundation for the Accreditation of Cellular Therapy (FACT).

    Transplant Code List




    Lung transplant, single; without cardiopulmonary bypass


    Lung transplant, single; with cardiopulmonary bypass


    Lung transplant, single; double (bilateral sequential or en bloc); without cardiopulmonary bypass


    Lung transplant, single; double (bilateral sequential or en bloc); with cardiopulmonary bypass


    Heart-lung transplant with recipient cardiectomy, pneumonectomy


    Bone marrow transplant, allogenic


    Bone marrow transplant, autologous


    Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions


    Intestinal allotransplantation; from cadaver donor


    Intestinal allotransplantation; from living donor


    Liver allotransplantation; orthoptopic, partial or whole, from cadaver or living donor, any age


    Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells


    Transplantation of pancreatic allograft

    CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

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