Kidney Transplant

Policy ID: S-124-019

Section: Surgery

Effective Date: March 01, 2021

Revised Date: November 22, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Kidney transplant, a treatment option for end-stage renal disease, involves the surgical removal of a kidney from a cadaver, living-related donor, or living-unrelated donor and transplantation into the recipient.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Kidney transplants with either a living or cadaver donor may be considered medically necessary for carefully selected individuals with end-stage renal disease.

Kidney re-transplant after a failed primary kidney transplant may be considered medically necessary in individuals who meet criteria for kidney transplantation.

Kidney transplant not meeting the criteria as indicated in this policy may be considered not medically necessary.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ may be considered medically necessary as an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

Procedure Codes

50300

50320

50323

50325

50327

50328

50329

50340

50360

50365

50370

50380

50547

Contraindications

Potential contraindications to solid organ transplant (subject to the judgment of the transplant center):

Known current malignancy, including metastatic cancer; or
Recent malignancy with high risk of recurrence; or
History of cancer with a moderate risk of recurrence; or
Systemic disease that could be exacerbated by immunosuppression; or
Untreated systemic infection making immunosuppression unsafe, including chronic infection; or
Other irreversible end-stage diseases not attributed to kidney disease; or
Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

Renal-Specific Criteria

Indications for renal transplant to include ANY of the following:

the individual requires chronic dialysis; or
glomerular filtration rate (GFR) less than or equal to 20 ml/min; or
creatinine level greater than six (6) mg/dL in symptomatic diabetic individuals

Note: Consideration for listing for renal transplant may start well before the creatinine level reaches this point, based on the anticipated time that an individual may spend on the waiting list.

Diagnosis Codes

N18.4

N18.5

N18.6

N18.9

Professional Statements and Societal Positions Guidelines

American Society of Transplant Surgeons et al-2011

The American Society of Transplant Surgeons, the American Society of Transplantation, the Association of Organ Procurement Organizations, and the United Network for Organ Sharing (2011) issued a joint position statement recommending modifications to the National Organ Transplant Act of 1984. The joint recommendation stated that the potential pool of organs from HIV-infected donors should be explored. With modern antiretroviral therapy, the use of these previously banned organs would open an additional pool of donors to HIV-infected recipients. The increased pool of donors has the potential to shorten waiting times for organs and decrease the number of waiting list deaths. The organs from HIV-infected deceased donors would be used for transplant only with individuals already infected with HIV. In 2013, the HIV Organ Policy Equity Act permitting the use of this group of organ donors.

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Adopting Policy

Internal Medical Policy Committee 1-20-2022 Annual Review

Internal Medical Policy Committee 11-29-2022 Revision- Effective January 02, 2023

Updated policy language

Internal Medical Policy Committee 5-23-2023 Annual Review

Internal Medical Policy Committee 5-14-2024 Annual Review

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-124-017

Section: Surgery

Effective Date: March 01, 2021

Last Reviewed: January 20, 2022

Archived Date: January 01, 2023

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Kidney transplants with either a living or cadaver donor may be considered medically necessary for carefully selected individuals with end-stage renal disease.

Kidney retransplant after a failed primary kidney transplant may be considered medically necessary in individuals who meet criteria for kidney transplantation.

Kidney transplant not meeting the criteria as indicated in this policy may be considered not medically necessary.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

Procedure Codes

50300

50320

50323

50325

50327

50328

50329

50340

50360

50365

50370

50380

50547

Contraindications

Potential contraindications to solid organ transplant (subject to the judgment of the transplant center):

Known current malignancy, including metastatic cancer; or
Recent malignancy with high risk of recurrence; or
History of cancer with a moderate risk of recurrence; or
Systemic disease that could be exacerbated by immunosuppression; or
Untreated systemic infection making immunosuppression unsafe, including chronic infection; or
Other irreversible end-stage diseases not attributed to kidney disease; or
Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

Renal-Specific Criteria

Indications for renal transplant include a creatinine level of greater than 8 mg/dL, or greater than 6 mg/dL in symptomatic diabetic individuals; however, consideration for listing for renal transplant may start well before the creatinine level reaches this point, based on the anticipated time that an individual may spend on the waiting list.

Diagnosis Codes

N18.4

N18.5

N18.6

N18.9

Professional Statements and Societal Positions Guidelines

American Society of Transplant Surgeons et al-2011

ND Committee Review

Internal Medical Policy Committee 1-19-2021 Adopting Policy

Internal Medical Policy Committee 1-20-2022 Annual Review

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Kidney Transplant

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer