ADULT HEART TRANSPLANT WAIT LIST - STATUS LEVELS 1-4
ALTERNATE NAMES
Adult Cardiac Transplant Wait List 1; Adult Cardiac Transplant Wait List 2; Adult Cardiac Transplant Wait List 3; Adult Cardiac Transplant Wait List 4; Adult Heart Transplant Wait List 1; Adult Heart Transplant Wait List 2; Adult Heart Transplant Wait List 3; Adult Heart Transplant Wait List 4
DESCRIPTION
A heart transplant is a life-saving surgical procedure to replace a diseased heart with a healthy heart from a deceased donor. Transplant is considered when an individual has “end-stage” heart failure. This means that the condition has become so severe that all treatments, other than heart transplant, have failed.
Coronary artery disease is the most common cause of end-stage heart failure. Other causes are hypertensive cardiovascular disease, valvular heart disease, Primary Myocardial Disease (PMD), and chemical agents like alcohol and certain medications.
Individuals in need of a heart transplant go through a careful selection process at a heart transplant center. The United Network for Organ Sharing (UNOS) manages the heart transplant waiting list. To be assigned a status level on the waiting list, a heart transplant status justification form must be submitted. After the submission of this form, UNOS assigns a status that reflects the medical urgency for transplant. UNOS will not assign a status without the submission of a form.
The status levels for individuals 18 years of age or older are:
Status 1: The individual is critically ill and requires mechanical support from one of the following:
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A non-dischargeable, surgically implanted, veno-arterial extracorporeal membrane oxygenation (VA ECMO);
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A non-dischargeable, surgically implanted, non-endovascular biventricular assist device (BiVAD); or
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A mechanical circulatory support device (MCSD) with severe ventricular arrhythmias (irregular heartbeats that originate in the lower heart chambers).
These individuals have the highest priority on the transplant list.
Status 2: The individual is on mechanical support and is dependent on at least one of the following:
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A non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD);
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Total artificial heart (TAH), BiVAD, right ventricular assist device (RVAD), or ventricular assist device (VAD) for single patients;
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A mechanical circulatory support device (MCSD) that is malfunctioning;
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A percutaneous endovascular MCSD;
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An intra-aortic balloon pump (IABP); or
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The individual is experiencing recurrent or sustained ventricular tachycardia or ventricular fibrillation occurring despite medical intervention.
Status 3: The individual has been admitted to the hospital and is receiving mechanical support from at least one of the following:
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A dischargeable LVAD and is exercising 30 days of discretionary time;
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Multiple inotropes or a single high dose inotrope and has hemodynamic monitoring;
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MCSD with hemolysis;
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MCSD with pump thrombosis;
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MCSD and has a device infection;
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MCSD and has bleeding;
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MCSD and has aortic insufficiency;
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Veno-arterial extracorporeal membrane oxygenation (VA ECMO) after 7 days;
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A non-dischargeable, surgically implanted, non-endovascular LVAD after 24 days;
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A percutaneous endovascular circulatory support device after 14 days;
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An IABP after 14 days; or
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An MCSD and has life threatening ventricular arrhythmia after 7 days.
Status 4: The individual has at least one of the following:
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A dischargeable LVAD;
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Is supported by inotropes without continuous hemodynamic monitoring;
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A diagnosis of congenital heart disease;
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A diagnosis of ischemic heart disease with intractable angina (chest pain despite treatment);
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A diagnosis of amyloidosis, hypertrophic cardiomyopathy, or restrictive cardiomyopathy; or
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Is a re-transplant (a second or subsequent transplantation) with International Society of Heart and Lung Transplantation (ISHLT) coronary allograft vasculopathy (CAV) grade 2-3, or New York Heart Association (NYHA) Class III-IV heart failure symptoms.
Status 5: The individual needs a dual heart transplant (heart-lung, heart-liver, heart-kidney) and does not meet criteria for status levels 1 to 4.
Status 6: Individuals classified as adult status level 6 do not meet the criteria for statuses 1-5 but are suitable for transplant.
NOTE: Adult status levels 1-4 are the most severe and are considered CAL-level conditions. Although severe, status levels 5 and 6 are not considered CAL-level conditions.
DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM/ICD-10-CM CODING
Diagnostic testing: Testing to determine if an individual has end-stage heart disease may include:
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Complete history and physical examination;
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Antibody tests;
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Chest x-ray;
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Twelve-lead electrocardiogram (ECG/EKG);
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Stress tests (exercise ECG/EKG or myocardial perfusion scan);
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Cardiopulmonary exercise test;
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Transthoracic/transesophageal echocardiogram (TTE);
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Cardiac catheterization;
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Cardiac magnetic resonance imaging (MRI);
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Lung function tests; and
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Computed tomography (CT) scan.
Signs and symptoms: Some signs and symptoms an individual on the heart transplant waiting list may experience are:
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Breathlessness on minimal exertion or at rest;
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Chronic cough or wheezing;
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Fatigue and weakness;
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Edema (swelling caused by too much fluid trapped in the body's tissues);
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Very rapid weight gain from fluid buildup;
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Nausea or lack of appetite;
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Tachycardia (high heart rate);
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Cognitive impairment (problems with memory, speech, or language);
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Difficulty concentrating or decreased alertness;
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Depression and anxiety; and
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Chest pain if heart failure is caused by a heart attack.
ICD-9: V42; V49.83; 428.0
ICD-10: I50; Z76.82; Z94.1
PROGRESSION
Time spent on the heart transplant waiting list is a key factor in determining who receives a donor heart. The wait for a heart transplant could be days to months. Some individuals may wait years. The amount of time an individual waits for a heart transplant depends on several factors including urgency of need, antibody levels, blood type, body size, and the number of donors in the area the individual lives in.
An individual can be taken off the waiting list due to a serious medical event such as a stroke, cancer, uncontrollable diabetes, infection, or kidney failure.
Donor hearts are in short supply. Some individuals die while waiting for a suitable donor heart.
TREATMENT
Individuals on the waiting list for a donor heart receive ongoing treatment for heart failure. Depending on the severity of their condition, they may receive mechanical assist devices to control the irregular heartbeat or help the heart pump blood before the actual heart transplant surgery.
SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation:
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Clinical history and examination that describes the diagnostic features of the impairment;
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Operative and procedure reports;
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Cardiology consultation reports;
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Imaging studies (ECG/EKG, chest x-ray, MRI) showing heart failure; and
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TTE showing indications of the need for mechanical assist devices such as ICDs or VADs.
Suggested Listings for Evaluation:
DETERMINATION
LISTING
REMARKS
Meets
4.02
4.04
4.05
4.06
Equals
4.02
4.04
4.05
4.06
*Adjudicators may, at their discretion, use the Medical Evidence of Record or the listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.
