Pancreas and Simultaneous Kidney/Pancreas Transplants
Effective for dates of service on or after December 1, 2005, pancreas and simultaneous
kidney/pancreas transplants are a benefit of the Texas Medicaid Program. Candidates are
limited to those patients who, based on sound patient selection criteria, would most likely
benefit from the transplant procedure on a long-term basis.
All transplants must be prior authorized, and documentation of medical necessity is
required at the time of authorization in order for reimbursement to be considered.
Documentation requirements are listed below.
Pancreas Transplant Alone
For the pancreas transplant alone, documentation of the following is required:
 Satisfactory kidney function (creatinine clearance greater than 40 mL/min) and
 Type 1 diabetes with secondary diabetic complications that are progressive despite
the best medical management. These complications include:
o Diabetic neuropathy
o Retinopathy
o Gastroparesis
o Autonomic neuropathy
 Extremely labile (brittle) insulin-dependent diabetes mellitus
OR

Recurrent, acute, and severe metabolic and potentially life-threatening complications
requiring medical attention, which include:
o Hypoglycemia
o Hyperglycemia
o Ketacidosis
o Failure of exogenous insulin-based management to achieve sufficient
glycemic control (HbA1c of greater than 8.0) despite aggressive conventional
therapy
o Insensibility to hypoglycemia
Simultaneous Kidney and Pancreas Transplant
For simultaneous kidney/pancreas transplants, the following must be documented:
 Type 1 diabetes mellitus with secondary diabetic complications that are progressive
despite the best medical management. These complications include:
o Diabetic neuropathy
o Retinopathy
o Gastroparesis
o Autonomic neuropathy
 Extremely labile (brittle) insulin-dependent diabetes melliltus
OR

Recurrent, acute and severe metabolic and potentially life-threatening complications
requiring medical attention which include:
o
o
o
o
o
Hypoglycemia
Hyperglycemia
Ketacidosis
Failure of exogenous insulin-based management to achieve sufficient
glycemic control (HbA1c of greater than 8.0) despite aggressive conventional
therapy
Insensibility to hypoglycemia
Contraindications
The following contraindications for transplant apply to both pancreas and simultaneous
kidney/pancreas transplants:
 Inadequate cardiac status, pulmonary, or liver function
 Ongoing or recurrent active infections that are not effectively treated
 Uncontrolled HIV/AIDS infection
 Malignancy (except non-melanoma skin cancers)
 Documented psychiatric instability, if severe enough to jeopardize incentive for
adherence to medical regimen
In addition, documentation of compliance with medical treatment regimens and plans of
care must be maintained in the client record. Documented compliance includes no active
alcohol or chemical dependency that interferes with compliance to a medical regimen.
For kidney a transplant alone, the criteria for the Kidney Transplant must be followed.
For more information, call the TMHP Contact Center at 1-800-925-9126.