Transplant Authorization Code List

Posted: 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 Resource 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
Code	Description
32851	Lung transplant, single; without cardiopulmonary bypass
32852	Lung transplant, single; with cardiopulmonary bypass
32853	Lung transplant, single; double (bilateral sequential or en bloc); without cardiopulmonary bypass
32854	Lung transplant, single; double (bilateral sequential or en bloc); with cardiopulmonary bypass
33935	Heart-lung transplant with recipient cardiectomy, pneumonectomy
38240	Bone marrow transplant, allogenic
38241	Bone marrow transplant, autologous
38242	Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions
44135	Intestinal allotransplantation; from cadaver donor
44136	Intestinal allotransplantation; from living donor
47135	Liver allotransplantation; orthoptopic, partial or whole, from cadaver or living donor, any age
48160	Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells
48554	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.