Transplantation of a normal pancreas is a treatment method for patients with diabetes mellitus. Pancreas transplantation can restore glucose control, and is intended to prevent, halt, or reverse the secondary complications of type 1 diabetes mellitus. Achievement of insulin independence with resultant decreased morbidity and increased quality of life is the primary health outcome of pancreas transplantation.
A solitary pancreas transplant may be considered medically necessary when the following criteria are met:
If patients has type 2 diabetes mellitus, must be insulin-dependent and have body mass index equal to or less than 32.
Solitary pancreas transplantation is considered not medically necessary for all other indications/conditions, and therefore, non-covered.
The following pancreas transplants are considered experimental/investigational and, therefore, not covered, due to the lack of evidence based literature:
Relative contraindications for pancreas transplantation include, but not limited to the following:
Documentation demonstrating medical necessity and a clear reason to circumvent these contraindications will be required with evaluation of this service.
Pancreas retransplant (PRTx) after a failed primary pancreas transplant may be considered medically necessary provided the individual meets the transplant criteria above.
Also, a third or subsequent pancreas transplant is considered not medically necessary in all cases.
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.