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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.47 Organ/Tissue Transplants : Heart Transplants
A heart transplant to a client for primary heart dysfunction must be documented as the client being unresponsive to more conventional and/or standard therapies to be considered for coverage.
Procedure code 33945 may be considered for prior authorization with medical necessity documentation that indicates a New York Heart Association (NYHA) Class III or IV cardiac disease with one of the following medical conditions:

Texas Medicaid & Healthcare Partnership
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