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Kidney transplant, a treatment option for end-stage renal disease (ESRD), involves the surgical removal of a kidney from a cadaver, living-related donor, or living-unrelated donor and transplantation into the recipient.
End-stage renal disease (ESRD) refers to the inability of the kidneys to perform their functions (ie, filtering wastes and excess fluids from the blood). ESRD, which is life-threatening, is also known as stage 5 chronic renal failure and is defined as a glomerular filtration rate (GFR) less than 15 mL/min/1.73 m². Dialysis is an artificial replacement for some kidney functions. Dialysis is used as a supportive measure in patients who do not want kidney transplants or who are not transplant candidates, and can also be used as a temporary measure in patients awaiting kidney transplant.
Kidney transplant, using kidneys from deceased or living donors, is an accepted treatment of ESRD. Based on data from the Organ Procurement and Transplantation Network, between 1998 and October 2016, 401,913 kidney transplants had been performed in the United States. Of these, 66% of the kidneys came from deceased donors and 34% from living donors.
Combined kidney and pancreas transplants and management of acute rejection of kidney transplant using either intravenous immunoglobulin or plasmapheresis are discussed in separate policies.
Kidney transplant is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
Related policies -
POLICYNo benefits will be provided for a covered transplant procedure unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
Kidney transplants are considered medically necessary for carefully selected candidates including, but not limited to, any one of the conditions (and ICD-10 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:
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).
Kidney retransplant after a failed primary kidney transplant may be considered medically necessary in patients who meet criteria for kidney transplantation.
Kidney transplant is considered investigational in all other situations.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Candidates for a kidney transplant need documentation of a progressive or terminal end-stage renal disease who otherwise have no immediate life threatening conditions, psychological impairments, and have a good support system.
Relative contraindications to kidney transplantation:
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:
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.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
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.
10/23/2013: Added policy statement to indicate that kidney retransplant after a failed primary kidney transplant may be considered medically necessary.
08/08/2014: Policy reviewed; description revised. Medically necessary policy statement on kidney retransplant after a failed primary kidney transplant updated to add "in patients who meet criteria for kidney transplantation." Added the following policy statement: Kidney transplant is considered investigational in all other situations.
08/31/2015: Code Reference section updated for ICD-10.
01/07/2016: Policy description updated. Policy statements unchanged.
06/01/2016: Policy number A.7.03.01 added. Policy Guidelines updated to add medically necessary and investigative definitions.
01/26/2017: Policy description updated regarding end-stage renal disease and data from the Organ Procurement and Transplantation Network. Policy statements unchanged.
SOURCE(S)Blue Cross & Blue Shield Association policy # 7.03.01
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.