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Solitary Pancreas Transplantation

Section: Surgery
Effective Date: July 01, 2018
Revised Date: August 13, 2019
Last Reviewed: September 26, 2019

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

48550 48551 48552 48554 S2065

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

48999

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

48550 48551 48552 48554 48999 S2065

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

48550 48551 48552 48554 S2065

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

E10.8  E10.10  E10.11  E10.21  E10.22  E10.29  E10.65 
E10.69  E10.618  E10.620  E10.621  E10.622  E10.628  E10.630 
E10.638  E10.641  E10.649  T86.890  T86.891  T86.892  T86.898 
T86.899  Z90.5

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