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A donor left kidney is usually transplanted to the right iliac fossa, with the renal artery anastomosed end-to-end to the hypogastric artery, and the renal vein end-to-side to the common iliac vein. The ureter is implanted into the bladder and (under special conditions) a ureteroureteral anastomosis or uretero-pyelostomy may be performed.

Kidney transplants are considered medically necessary for carefully selected candidates including, but not limited to, any one of the conditions (and ICD-9 diagnosis codes listed in the "Code Reference" section) which cause end-stage renal disease.

Kidney transplantation is not medically necessary in patients with the following absolute contraindications:

• Known current malignancy, including metastatic cancer;
• Recent malignancy with a high incidence of recurrence;
• Untreated systemic infection making immunosuppression unsafe, including chronic infection; or
• Other irreversible end-stage disease not attributed to kidney disease.

HIV positivity is not an absolute contraindication to transplant.  Each individual transplant center will determine patient selection criteria for HIV positive patients. (See Policy Guidelines).

None

Relative contraindications to kidney transplantation:

1. History of cancer with a moderate risk of recurrence;
2. Systemic disease that could be exacerbated by immunosuppression;
3. Psychosocial conditions or chemical dependence affecting the ability to adhere to therapy; or
4. Lack of adequate cardiopulmonary reserve.
   
   

HIV-positive patients who meet the following criteria, as stated in the 2001 guidelines of the American Society of Transplantation, could be considered candidates for kidney transplantation:

1. CD4 count >200 cells per cubic millimeter for >6 months
2. HIV-1 RNA undetectable
3. On stable anti-retroviral therapy >3 months
4. No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm), and
5. Meeting all other criteria for transplantation.
   

Indications for renal transplant include a creatinine level of greater than 8 mg/dL, or greater than 6 mg/dL in symptomatic diabetic patients. However, consideration for listing for renal transplant may start well before the creatinine level reaches this point, based on the anticipated time that a patient may spend on the waiting list.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

5/1/2002: Type of Service and Place of Service deleted

7/21/2005: Reviewed by MPAC; "HIV positivity is not an absolute contraindication to transplant.  Each individual transplant center will determine patient selection criteria for HIV positive patients."

10/17/2005: Code Reference table updated: CPT codes 50323, 50325, 50327, 50328, 50329, 50380 added; ICD-9 procedure codes 55.52, 55.53, 55.54, 55.61, 55.69, 00.91, 00.92, 00.93 added; diagnosis codes 250.40, 250.42, 274.11, 403.01, 403.11, 403.91, 581.81, 584.7, 753.3 added, 275.49 5th digit added, V42.0 deleted, other codes were moved and placed in numerical order.

10/25/2005: Code Reference Table updated: CPT codes revised: 50300, 50320, 50340, 50360, 50365. ICD-9 Diagnosis codes revised: 189.0, 203.00, 203.01, 250.40-250.43, 270.0, 271.8, 272.7, 274.10, 274.11, 274.19, 275.49, 277.3, 287.0, 446.0, 453.3, 582.1, 583.6, 583.89, 583.9, 584.5, 590.00-590.01, 593.81, 599.6, 710.0, 753.0, 753.12, 753.13, 753.14, 753.16, 866.00-866.03, 866.10, 866.11, 866.12, 866.13, 963.8, 996.81

11/8/2005:  Code Reference section updated, 5th digit added to ICD9 diagnosis codes 599.60, 599.69; 4th digit added to codes 585.1-585.9, description revised

03/13/2006:  Coding updated.  CPT4 2006 revisions added to policy.

9/12/2006:  Coding updated.  ICD9 2006 revisions added to policy.

1/14/2008: Policy reviewed, no changes

9/10/2008: Annual ICD-9 updates effective 10-1-2008 applied

12/19/2008: Policy reviewed, prior authorization language removed

4/23/2009: Policy reviewed, no changes

9/29/2009: Code reference section updated. Description revised for ICD-9 codes 584.5 and 584.7.

08/11/2011:  Policy statement updated to add the following absolute contraindications to kidney transplantation: known current malignancy, including metastatic cancer; recent malignancy with a high incidence of recurrence; untreated systemic infection making immunosuppression unsafe, including chronic infection; or other irreversible end-stage disease not attributed to kidney disease. Updated policy guidelines regarding patient selection criteria. Also added statement regarding prior authorization requirements to the policy statement. Deleted outdated references from the Sources section.

07/17/2012: Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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