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Date:  Tuesday, February 21, 1995
Contact:  Anne Verano (202) 690-6145

Medicare Covers Lung Transplants

Medicare will cover lung transplantation in hospitals with documented experience and success in performing that procedure, HHS Secretary Donna E. Shalala has announced.

"Medicare will help pay for lung transplants only in facilities with the demonstrated quality of services necessary for this complex procedure," Secretary Shalala said.

A notice setting forth the requirements has been published in the Federal Register. Although the notice establishes a national policy for Medicare coverage of lung transplantation, the program has been paying for that procedure when approved by Medicare contractors in individual cases.

The contractors -- health insurance companies that administer the Medicare program in every state -- are authorized to cover a procedure that they deem reasonable and medically necessary when a national coverage policy has not been made.

Under the new rules, a hospital applying for approval as a Medicare Lung Transplant Center must present data on its lung transplants and outcomes for 10 or more patients in each of the two previous years. The hospital must document a one-year survival rate of at least 69 percent and a two-year survival rate of 62 percent for lung transplant patients.

A hospital will be required to perform a minimum of 10 lung transplants a year to retain its status in the Medicare program. This mandate is designed to ensure that the transplant team maintains the skills needed for quality performance.

The notice specifies that lung transplantation is a procedure to be used only when it would offer a patient a realistic chance for recovery from end-stage lung disease after all other therapies have failed.

Hospitals are required to have written policies on selection of patients for lung transplantation. The notice provides a list of factors hospitals should consider in selecting patients to increase the odds for successful outcomes.

Bruce C. Vladeck, administrator of the Health Care Financing Administration, explained that the Medicare decision to cover lung transplants "is based on extensive research of medical literature and clinical records by HCFA and other agencies.

"There is a great body of clinical evidence that lung transplants can produce good outcomes when performed by experienced medical teams on carefully selected patients," Vladeck said.

The Office of Health Technology Assessment, in the Public Health Service's Agency for Health Care Policy and Research, studied lung transplantation and found the procedure to be safe and effective in treating end-stage lung disease. Similar findings were reported by the National Heart, Lung and Blood Institute of the National Institutes of Health, PHS.

Medicare already covers kidney, heart and liver transplants. The program helps to pay for heart and liver transplants only when performed in facilities meeting special quality standards such as those announced for lung transplantation.

A combined heart/lung transplantation will be covered by Medicare when done in a hospital approved for either heart or lung transplants.

It is estimated that under current policy, Medicare would help pay for 162 lung transplants in fiscal year 1995 at a cost of $18 million. The national coverage policy is expected to result in payment for additional transplants in FY 1995.