Lung Transplantation — CPB 0598 | AETNA Coverage Update

Aetna modified CPB 0598 for lung transplantation, effective December 4, 2025. Here's what billing teams need to know before submitting claims under CPT 32851–32854.

Aetna, a CVS Health company, updated its lung transplantation coverage policy under CPB 0598 in the Aetna system. The update affects CPT codes 32850, 32851, 32852, 32853, and 32854 for lung transplant procedures, plus related codes including 0493U and 0540U for donor-derived cell-free DNA testing and Category III codes 0494T–0496T for ex vivo organ perfusion. If your team bills for lung transplantation or post-transplant monitoring, this policy sets the rules for what gets paid and what gets denied.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Lung Transplantation
Policy Code	CPB 0598
Change Type	Modified
Effective Date	December 4, 2025
Impact Level	High
Specialties Affected	Thoracic surgery, pulmonology, transplant medicine, cardiothoracic surgery, gastroenterology (fundoplication)
Key Action	Audit your documentation against CPB 0598 disease-specific selection criteria before billing CPT 32851–32854

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Aetna Lung Transplantation Coverage Criteria and Medical Necessity Requirements 2025

The Aetna lung transplantation coverage policy under CPB 0598 ties medical necessity to two parallel tracks. First, the member must meet the transplanting institution's selection criteria. If those criteria aren't documented, the member must meet Aetna's general selection criteria plus any applicable disease-specific selection criteria.

That distinction matters for your authorization submissions. If you're billing for a patient at a transplant center with published criteria, document that clearly. If you're not, you'll need to satisfy Aetna's general and disease-specific requirements—and missing either layer is a fast path to claim denial.

Qualifying Conditions

Aetna considers lung transplantation medically necessary for the following conditions (not an all-inclusive list):

Disease-Specific Criteria: Cystic Fibrosis

For cystic fibrosis, Aetna requires the member to meet general selection criteria plus at least two of the following clinical deterioration signs:

Two of these must be documented. One isn't enough.

Disease-Specific Criteria: Emphysema (Including Alpha1-Antitrypsin Deficiency)

For emphysema, Aetna requires the general selection criteria plus both of the following:

#	Covered Indication Copy
1	Hospitalizations for COPD exacerbation with hypercapnia (pCO2 ≥ 50 mm Hg) in the preceding year, plus one or more of: declining body mass index, increasing oxygen requirements, reduced serum albumin, or presence of cor pulmonale
2	[Additional criterion per full CPB 0598 — review the complete policy document for full text]

The "both criteria" requirement here is strict. Document each individually in your authorization package.

Authorization and Prior Authorization Requirements

CPB 0598 does not specify prior authorization requirements in the available policy text. Prior authorization requirements for lung transplantation should be confirmed directly with Aetna before the procedure date. Given that CPT 32853 and 32854 (double/bilateral lung transplant with cardiopulmonary bypass) represent significant reimbursement events, verify your authorization requirements with Aetna provider relations before December 4, 2025. Don't assume — confirm.

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Aetna Lung Transplantation Exclusions and Non-Covered Indications

The policy lists contraindications that make a patient ineligible for coverage, though the full contraindications list is in the complete CPB 0598 document. Beyond patient-level contraindications, several procedure codes in this policy have explicit coverage limitations.

Fundoplasty codes (CPT 43280, 43325, 43327, 43328) carry a specific restriction: not covered if the patient is asymptomatic. This is written directly into the code descriptions. If you bill these codes for an asymptomatic patient, expect a claim denial.

HCPCS J0202 (alemtuzumab injection, 1 mg) is explicitly listed as not covered for indications listed in CPB 0598. Don't include J0202 on lung transplant claims under this policy.

The donor-derived cell-free DNA codes (0493U and 0540U), the ex vivo perfusion codes (0494T, 0495T, 0496T), and CPT 43257 are all grouped together in the source policy data without a specific covered or not-covered designation. Review the complete CPB 0598 text for their specific coverage conditions before billing.

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Coverage Indications at a Glance

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Aetna Lung Transplantation Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Lung Transplantation Under CPB 0598

Covered CPT Codes (When Selection Criteria Are Met)

CPT Codes With Conditional Coverage — Review Full CPB 0598

Not Covered CPT Codes (Conditional Exclusions)

HCPCS Codes Covered (When Selection Criteria Are Met)

Code	Type	Description Copy
J7504	HCPCS	Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg
J7511	HCPCS	Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg

HCPCS Codes Not Covered

Code	Type	Description	Reason Copy
J0202	HCPCS	Injection, alemtuzumab, 1 mg	Explicitly not covered for indications listed in CPB 0598

Key ICD-10-CM Diagnosis Codes

The full ICD-10 code set for CPB 0598 includes 332 codes. Review the complete policy at app.payerpolicy.org/p/aetna/0598 for the full list.

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