Cardiac transplantation is covered under Medicare when performed in a facility which is
approved by Medicare as meeting institutional coverage criteria. On April 6, 1987, CMS
Ruling 87-1, "Criteria for Medicare Coverage of Heart Transplants" was published in the
"Federal Register." For Medicare coverage purposes, heart transplants are medically
reasonable and necessary when performed in facilities that meet these criteria. If a
hospital wishes to bill Medicare for heart transplants, it must submit an application and
documentation, showing its ongoing compliance with each criterion.
If a contractor has any questions concerning the effective or approval dates of its hospitals,
it should contact its RO.
A. - Effective Dates
The effective date of coverage for heart transplants performed at facilities applying after
July 6, 1987, is the date the facility receives approval as a heart transplant facility.
Coverage is effective for discharges October 17, 1986 for facilities that would have
qualified and that applied by July 6, 1987. All transplant hospitals will be recertified
under the final rule, Federal Register / Vol. 72, No. 61 / Friday, March 30, 2007, / Rules
and Regulations.
The CMS informs each hospital of its effective date in an approval letter
B. - Drugs
Medicare Part B covers immunosuppressive drugs following a covered transplant in an
approved facility.
C. - Noncovered Transplants
Medicare will not cover transplants or re-transplants in facilities that have not been
approved as meeting the facility criteria. If a beneficiary is admitted for and receives a
heart transplant from a hospital that is not approved, physicians' services, and inpatient
services associated with the transplantation procedure are not covered.
If a beneficiary received a heart transplant from a hospital while it was not an approved
facility and later requires services as a result of the noncovered transplant, the services are
covered when they are reasonable and necessary in all other respects.
