Organ Transplant Policy Comparison
I.

Pancreas
2/9/2016
Full Coverage Details
BCBS
Combined Pancreas-Kidney
transplant may be considered
medically necessary in diabetic
patients with uremia.

Pancreas transplant after a prior
kidney transplant may be
considered medically necessary in
patients with insulin dependent
diabetes mellitus.

Pancreas transplant alone may be
considered medically necessary in
patients with severely disabling and
potentially life-threatening
complications due to hypoglycemia
(abnormally low level of glucose in
the blood) unawareness and labile
diabetes that persists in spite of
optimal medical management.

Pancreas retransplant after a failed
primary pancreas transplant may
be considered medically necessary
for all three types of pancreas
transplants (i.e., combined pancreaskidney transplant, pancreas transplant
after a prior kidney transplant, and
pancreas transplant alone).
Medicaid
3.1 General Criteria
Medicaid/NCHC covers procedures, products, and services related to
this policy when they are medically necessary and
a. the procedure, product, or service is individualized, specific, and
consistent with symptoms or confirmed diagnosis of the illness or
injury under treatment, and not in excess of the recipient’s needs;
b. the procedure, product, or service can be safely furnished, and no
equally effective and more conservative or less costly treatment is
available; AND
c. the procedure, product, or service is furnished in a manner not
primarily intended for the convenience of the recipient, the
recipient’s caretaker, or the provider.
3.2 Specific Criteria
Pancreas transplantation, (a pancreas alone, simultaneous with a kidney
transplant, or following a kidney transplant) may be covered under the
Medicaid/NCHC Program when it is determined to be medically
necessary because the following medical criteria are met.
a. Candidates for any type of pancreas transplant should meet ALL
of the following criteria:
1. Adequate cardiopulmonary status;
2. Absence of active infection;
3. Absence of uncontrolled HIV infection. HIV infection is considered controlled
when the following criteria are met:
(a) the CD4 count >200 cells/mm-three (3) for > six (6) months; and (b) the HIV-1
RNA undetectable; and (c) the recipient is stable on anti-retroviral therapy > three
(3) months; and (d) the recipient has no other complications from AIDS (e.g.,
opportunistic infection, including aspergillus, tuberculosis, coccidioses mycosis,
resistant fungal infections, Kaposi’s sarcoma, or other neoplasm;
4. No history of malignancy within five (5) years of transplantation, excluding
nonmelanomatous skin cancers,
5. Documentation of recipient compliance with medical management.
b. Candidates for pancreas transplant alone should additionally meet
ONE of the following severity of illness criteria:
1. documentation of severe hypoglycemia unawareness as evidence by chart notes or
emergency room visits; OR
2. documentation of potentially life-threatening labile diabetes as evidenced by chart
notes or hospitalization for diabetic ketoacidosis.
c. Listed below are the clinical indications for the three (3) types of
pancreas transplants:
1. Combined pancreas-kidney transplant may be considered medically necessary in
diabetic recipients with uremia.
2. Pancreas transplant after a prior kidney transplant may be considered medically
necessary in recipients with insulin dependent diabetes mellitus.
3. Pancreas transplant alone may be considered medically necessary in recipients
with severely disabling and potentially life-threatening complications due to
hypoglycemia (abnormally low level of glucose in the blood) unawareness and labile
diabetes that persists in spite of optimal medical management.
4. Pancreas re-transplant after a failed primary pancreas transplant may be
considered medically necessary for all three types of pancreas transplants (i.e.,
combined pancreas-kidney transplant, pancreas transplant after a prior kidney
transplant, and pancreas transplant alone).
Organ Transplant Policy Comparison
II.








Pancreas
2/9/2016
Coverage Exclusion
BCBS
poor physiologic age;
significant emotional problems
that may impair the patient’s
ability to adhere to follow-up;
recent substance abuse;
current tobacco use (impairs
wound and microvascular
healing);
history of non-compliance with
medical management;
lack of support to the extent that
adequate follow-up and adherence
to post operative treatment plan is
impaired;
other major organ system disease
or infection, including major
vascular disease;
morbid obesity;
uncontrolled HIV positive
patients.
Medicaid
4.1 General Criteria
Procedures, products, and services related to this policy are not covered
when
a. the recipient does not meet the eligibility requirements listed in
Section 2.0;
b. the recipient does not meet the medical necessity criteria listed in
Section 3.0;
c. the procedure, product, or service unnecessarily duplicates another
provider’s
procedure, product, or service; or
d. the procedure, product, or service is experimental or investigational.
4.2 Specific Criteria
a. Pancreas transplantation is not covered for:
1. indications other than those cited above.
2. organs sold rather than donated to a recipient.
3. artificial organs or human organ transplant service for which the cost
is covered or funded by governmental, foundation, or charitable grants.
b. Contraindications for the combined pancreas/kidney transplantation
include the
following:
1. significant emotional problems that may impair the recipient’s
ability to adhere
to follow-up;
2. recent substance abuse;
3. current tobacco use (impairs wound and microvascular healing);
4. history of non-compliance with medical management;
5. lack of support to the extent that adequate follow-up and adherence
to post
operative treatment plan is impaired;
6. other major organ system disease or infection, including major
vascular disease;
7. morbid obesity; or
8. uncontrolled HIV positive recipients.
Organ Transplant Policy Comparison
III.
Pancreas
2/9/2016
BCBS Policy Guidelines
It is recommended that all transplant requests be reviewed by the Plan Medical Director or his or her designee. Only
those patients accepted for transplantation by an approved transplantation center and actively listed for transplant
should be considered for precertification or prior approval. Guidelines should be followed for transplant network or
consortiums, if applicable.
Guidelines should be followed for transplant networks, where applicable.
Candidates for any type of pancreas transplant should meet ALL of the following criteria:
A.) Adequate cardiopulmonary status, and
B.) Absence of active infection, and
C.) Absence of uncontrolled HIV infection. HIV infection is considered controlled when the following
criteria are met:
1) the CD4 count >200 cells/mm-3 for >6 months; and
2) the HIV-1 RNA undetectable; and
3) the patient is stable on anti-retroviral therapy >3 months; and
4) the patient has no other complications from AIDS (e.g., opportunistic infection, including
aspergillus, tuberculosis, coccidioses mycosis, resistant fungal infections, Kaposi’s sarcoma, or
other neoplasm; and
D.) No history of malignancy within 5 years of transplantation, excluding nonmelanomatous skin cancers,
and
E.) Documentation of patient compliance with medical management.
Candidates for pancreas transplant alone should additionally meet one of the following severity of
illness criteria:
1) documentation of severe hypoglycemia unawareness as evidence by chart notes or emergency
room visits; OR
2) documentation of potentially life-threatening labile diabetes as evidenced by chart notes or
hospitalization for diabetic ketoacidosis.
IV.
None.
Medicaid Policy Guidelines