Simultaneous pancreas/kidney transplantation (SPK) involves the surgical removal of a pancreas and kidney from the same cadaver donor, and the implantation of the pancreas and kidney into the recipient.
SPK may be considered medically necessary for individuals who have insulin-dependent diabetes mellitus with uremia or end-stage renal disease.
Candidates for all types of pancreas/kidney transplant may be considered medically necessary when ALL of the following are met:
Absolute contraindications for transplant recipients include, but are not limited to, the following:
Relative contraindications to pancreas/kidney transplantation include, but are not limited to, the following:
SPK transplantation performed for any other indications than those listed in this policy or for those individuals presenting with an absolute contraindication are considered not medically necessary.
One pancreas alone, one pancreas after kidney or one simultaneous pancreas/kidney (SPK or SPLK) re-transplantation after failure of the primary graft may be considered medically necessary when the individual meets ALL the transplant criteria above.
One pancreas alone, one pancreas after kidney or one simultaneous pancreas/kidney (SPK or SPLK) re-transplantation for all other indications 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 may be considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.
Covered Diagnosis Codes for Procedure codes: 48550, 48551, 48552, 48554, 48556, S2065
Covered Diagnosis Codes for Procedure codes: 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 50547