Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac Myopathy.
Treatment:  Heart transplant.

The insurer denied coverage for heart transplant.  The denial is overturned.
 
This is the case of an adult patient with a history of ischemic dilated cardiomyopathy and is being considered for a combined heart/kidney transplant. The heart transplant committee found the patient to be eligible for a heart transplant based upon New York Heart Association (NYHA) class 3-4 heart failure symptoms refractory to medical or surgical therapy with his life expectancy without a transplant to be less than life expectancy with a transplant. He was approved for the transplant by the committee for combined heart kidney pending financial clearance.

Vieira noted in "Heart transplantation candidacy" Current Opinion Organ Transplant 2021 that "timely referral of eligible candidates for consideration of advanced therapies, such as a heart transplantation or mechanical circulatory support is essential. The characteristics of heart transplantation candidates have changed significantly over the years, leading to a more complex evaluation process." The author noted that "Moreover, patients with chronic infectious diseases, as well as malignancies, are being currently considered acceptable candidates for transplantation."
	
Mancini noted in "Heart transplantation in adults: Indications and contraindications" in UpToDate 2023 that the "indications for combined organ transplantation include patients with severe irreversible disease of the heart and another organ system, isolated cardiac transplantation should not be performed; multiorgan transplantation may be an option in some of these cases but requires careful consideration given the complex medical issues involved. The author also noted that patients with end-stage heart disease who also have renal failure with indication for kidney transplantation can be considered for dual organ transplantation." Thus, in this case the patient should be considered for combined kidney heart transplant and not kidney only.
	
Rossi noted in "Kidney transplantation in adults: Evaluation of the potential kidney transplant recipient" in UpToDate 2023 that "Severe ischemic cardiomyopathy (ejection fraction <30 percent) is a relative contraindication to kidney transplantation. Combined kidney-heart transplantation may be considered in select patients who require transplantation of both organs. In addition, the patient should be free of all untreated, active infection before transplantation. Dental infections should be treated prior to transplantation." Thus, this patient meets the guidelines for a combined kidney heart and not kidney alone. In terms of his dental workup-he has gone to the dentist and is in the process of having several teeth extracted. 
	
Allen noted in American Society of Transplantation (AST) Infectious Diseases Community of Practice Post-transplant lymphoproliferative disorders, Epstein-Barr virus infection, and disease in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice" in Clin Transplant 2019 that "EBV serostatus should be determined on all transplant recipients and donors in order to identify the patients at high risk for Post-transplant lymphoproliferative disorders (PTLD) development (Strong/high)." 

Therefore, the heart surgery in the form of a combined heart-kidney transplant is medically indicated for this patient and he does meet listing criteria for the transplant program as he was felt to be a suitable candidate for transplant. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Surgical Procedure 33945 on the Heart (heart transplant and inpatient admission) is substantiated.