CommercialCoverageHigh impact
Heart & Heart/Lung Transplant 7.02.06
Excellus BlueCross BlueShield·Cardiology, Cardiothoracic Surgery, Pulmonology·Transplants
Effective date
Jul 17, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their heart and heart-lung transplant policy effective July 17, 2025, establishing specific medical criteria for transplant coverage and requiring comprehensive pre-transplant evaluations with annual reauthorizations. The policy details acceptable, probable, and inadequate indications for cardiac transplantation along with contraindications for both procedures.
Action Required
By July 17, 2025: Billing team must ensure all heart and heart-lung transplant cases meet the updated medical criteria before submitting claims. Verify pre-transplant evaluation documentation includes all required components (clinical evaluation, psycho-social assessment, oral health evaluation, lab tests, cardiac assessment, pulmonary assessment, and age-appropriate screening). Set up annual reauthorization reminders for patients on transplant waiting lists. Claims not meeting the specific medical necessity criteria will be denied.