Heart-Lung Transplant — CPB 0597 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0597 governing heart-lung transplant coverage, effective December 4, 2025. Billing teams managing CPT codes 33930–33945 need to confirm documentation aligns with updated selection criteria before submitting claims.

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Aetna modified CPB 0597, its heart-lung transplant coverage policy, with an effective date of December 4, 2025. The policy covers CPT codes 33930 through 33945 and HCPCS codes S2054, S2055, S2060, and S2061 when strict medical necessity and selection criteria are met. If your team handles heart-lung transplant billing for Aetna members, the documentation thresholds in this updated policy are what will make or break your claims.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health Company
Policy	Heart-Lung Transplant — CPB 0597
Policy Code	CPB 0597
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	High
Specialties Affected	Cardiothoracic Surgery, Transplant Programs, Pulmonology, Cardiology, Revenue Cycle
Key Action	Verify all selection criteria documentation is complete and on file before submitting claims under CPT 33930–33945 after December 4, 2025

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Aetna Heart-Lung Transplant Coverage Criteria and Medical Necessity Requirements 2025

The Aetna heart-lung transplant coverage policy is specific about who qualifies. This isn't a "submit and see" situation. Aetna requires medical necessity documentation before reimbursement flows on any CPT code in the 33930–33945 range.

To meet medical necessity under CPB 0597, a member must have severe refractory heart failure combined with either end-stage lung disease or irreversible pulmonary hypertension. Both conditions must be present. One alone doesn't qualify.

Aetna lists seven qualifying diagnoses. These include cystic fibrosis with severe heart failure (ICD-10 E84.0–E84.9), chronic obstructive pulmonary disease with severe heart failure (J40–J47.9), Eisenmenger's complex with irreversible pulmonary hypertension and severe heart failure, irreversible primary pulmonary hypertension with severe heart failure, connective tissue disease causing pulmonary fibrosis with uncontrollable pulmonary hypertension, congenital heart disease with pulmonary hypertension not correctable by standard cardiac surgery (Q20.0–Q28.9), and severe coronary artery disease or cardiomyopathy (I25.10–I25.9, I42.0–I43) with irreversible pulmonary hypertension.

For Eisenmenger's complex and primary pulmonary hypertension, work with your certified coder to select the appropriate code from the pulmonary heart disease range (I26.01–I27.9). The policy source maps that range to pulmonary heart disease generally — confirm the specific code assignment against the full CPB 0597 policy text before submitting.

One critical coverage distinction is buried in a footnote but it controls claims. Heart-lung transplantation is not medically necessary when lung transplantation alone will restore right ventricular function. Your clinical documentation must show that RV function would not be restored by lung transplant alone. If that distinction isn't addressed in the chart, expect a claim denial.

Selection Criteria That Gate Coverage

Even when diagnosis criteria are met, Aetna requires the member to meet the transplanting institution's selection criteria. If the institution doesn't have its own criteria, Aetna applies its own nine-point checklist. Every item on that list is a potential denial trigger.

The nine criteria are:

If your transplant program is submitting claims under CPT 33930–33945 and the chart doesn't address all nine criteria, you're at risk. Confirm prior authorization requirements with Aetna directly for transplant procedures, and verify that your pre-authorization documentation maps to these criteria before the case goes forward.

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Aetna Heart-Lung Transplant Exclusions and Non-Covered Indications

The clearest exclusion in this coverage policy is procedural, not diagnostic. Aetna will not cover heart-lung transplantation when lung transplant alone would restore right ventricular function. This isn't a gray area — it's a stated denial basis.

Aetna also excludes the procedure when any absolute contraindications are present. These include conditions that make the member an unsuitable candidate under the selection criteria listed above — active malignancy, uncontrolled infection, or organ function below the stated thresholds.

The practical risk for billing teams is this: if clinical documentation doesn't explicitly address RV function and rule out lung transplant as a standalone solution, Aetna has grounds to deny on medical necessity. Build that documentation requirement into your pre-authorization checklist now.

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Coverage Indications at a Glance

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Aetna Heart-Lung Transplant Billing Guidelines and Action Items 2025

Heart-lung transplant claims carry significant financial exposure for your program. A denied claim in this category is not a rounding error. These action items are specific to CPB 0597 in the Aetna system, effective December 4, 2025.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Heart-Lung Transplant Under CPB 0597

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

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