Description

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. 

Criteria

A solitary pancreas transplant may be considered medically necessary when the following criteria are met: 

• Pancreas transplant after a prior kidney transplant (PAK) for patients with insulin dependent diabetes; or
• Pancreas transplant alone (PTA) for patients with severely disabling and potentially life-threatening complications due to hypoglycemia unawareness and labile insulin dependent diabetes that persists in spite of optimal medical management. 

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. 

Procedure Codes

The following pancreas transplants are considered experimental/investigational and, therefore, not covered, due to the lack of evidence based literature: 

• Living donor pancreas transplantation: 
  • Partial pancreas transplantation; or
  • Segmental pancreas transplantation. 

Procedure Codes

Relative contraindications for pancreas transplantation include, but not limited to the following: 

• Known current malignancy, including any metastatic cancer; or
• Recent malignancy with high risk of recurrence; or
• Ongoing or recurring infections that are not effectively treated; or
• Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery; or
• Demonstrated patient noncompliance, which places the organ at risk by not adhering to medical recommendations; or
• Potential complications from immunosuppressive medications are unacceptable to the patient; or 
• Acquired immune deficiency syndrome (AIDS) (diagnosis based on CDC definition of CD4 count, 200 cells/mm³) unless the following are noted: 
  • CD4 count greater than 200 cells/mm  for greater than six (6) months; or
  • HIV-1 RNA undetectable; or
  • On stable anti-retroviral therapy greater than three (3) months; or
  • No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi's sarcoma or other neoplasm). 
• Systemic disease that could be exacerbated by immunosuppression; or
• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy. 

Documentation demonstrating medical necessity and a clear reason to circumvent these contraindications will be required with evaluation of this service. 

Procedure Codes

Restransplantation 

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. 

Procedure Codes

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.

Diagnosis Codes

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