Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Pancreas transplant after a prior kidney transplant may be considered medically necessary in individuals with insulin-dependent diabetes.
A combined pancreas and kidney transplant may be considered medically necessary in insulin-dependent diabetic individuals with uremia.
Pancreas transplant alone may be considered medically necessary in individuals with severely disabling and potentially life-threatening complications due to hypoglycemia unawareness and labile insulin-dependent diabetes that persists despite optimal medical management.
Pancreas re-transplant after a failed primary pancreas transplant may be considered medically necessary in individuals who meet criteria for pancreas transplantation.
Pancreas transplant not meeting the criteria as indicated in this policy is 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
48550 | 48551 | 48552 | 48554 | 48556 | 48999 | 50300 |
50320 | 50323 | 50325 | 50327 | 50328 | 50329 | 50340 |
50360 | 50365 | 50370 | 50380 | 50547 | S2065 |
