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Medical & Coding Policies
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Out-of-State & Non-Network
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DESCRIPTIONIn autologous islet transplantation, during the pancreatectomy procedure, islet cells are isolated from the resected pancreas using enzymes, and a suspension of the cells is injected into the portal vein of the patient’s liver. Once implanted, the beta cells in these islets begin to make and release insulin. In the case of allogeneic islet cell transplantation, cells are harvested from the deceased donor’s pancreas, processed, and injected into the recipient’s portal vein. Up to 3 donor pancreas transplants may be required to achieve insulin independence. Allogeneic transplantation may be performed in the radiology department.Chronic Pancreatitis Patients with chronic pancreatitis may experience intractable pain that can be relieved with a total or near total pancreatectomy. However, the pain relief must be balanced against the certainty that the patient will be rendered an insulin dependent diabetic. Autologous islet cell transplantation has been investigated as a technique to prevent this serious morbidity. Specifically, during the pancreatectomy procedure a suspension of isolated islet cells is created from the resected pancreas specimen and then injected into the portal vein of the liver, where the cells function as a free graft. Type 1 Diabetes Allogeneic islet transplantation has been used for type1 diabetes to restore normoglycemia and, ultimately, reduce or eliminate the long-term complications of diabetes such as retinopathy, neuropathy, nephropathy, and cardiovascular disease. Islet transplantation potentially offers an alternative to whole-organ pancreas transplantation. However, a limitation of islet transplantation is that 2 or more donor organs are usually required for successful transplantation, although experimentation with single-donor transplantation is occuring. A pancreas that is rejected for whole-organ transplant is typically used for islet transplantation. Therefore, islet tranplantation is recommended only for patients with frequent and severe metabolic complications who have consistently failed to achieve control with insulin-based management. Islet cells are subject to regulation by the FDA, which classifies allogeneic islet cell transplantation as somatic cell therapy, requiring premarket approval. Islet cells also meet the definition of a drug under the federal Food, Drug, and Cosmetic Act. Clinical studies to determine safety and effectiveness outcomes of allogeneic islet transplantation must be conducted under FDA investigational new drug (IND) regulation. While at least 35 IND application have been submitted to the FDA, no center has yet to submit a biologics license application.
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POLICYNo benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through Case Management from Blue Cross & Blue Shield of Mississippi.Autologous pancreas islet cell transplantation may be considered medically necessary as an adjunct to a total or near total pancreatectomy in patients with chronic pancreatitis. Autologous pancreas islet cell transplantation is a specialized procedure that may require referral to an out of network facility. Allogeneic islet transplantation is considered investigational for the treatment of type 1 diabetes.
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POLICY EXCEPTIONSNone
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POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY11/2001: Approved by Medical Policy Advisory Committee (MPAC)3/6/2002: Prior authorization through Case Management added 4/18/2002: Type of Service and Place of Service deleted 5/29/2002: Code Reference section updated 10/25/2005: Code Reference section updated, CPT code 48146 deleted from covered codes, ICD9 Procedure codes 52.51 - 52.59, 52.6, 52.86 deleted from covered codes, HCPCS codes G0341 and G0342 added to covered codes 1/4/2007: Policy reviewed, investigational statement per allogeneic transplant for type 1 diabetes added 1/9/2007: Code reference section updated. CPT codes 0141T, 0142T, 0143T, G0343, and S2102 added to the non-covered codes. CPT codes G0341 and G0342 moved to non-covered 4/23/2009: Policy reviewed, no changes 07/15/2010: Policy description updated to include information regarding autologous islet transplantation. Policy statement unchanged. 08/02/2011: Policy reviewed; no changes. 07/17/2012: Policy reviewed; no changes.
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SOURCE(S)Blue Cross Blue Shield Association policy # 7.03.12
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CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. Covered Codes
This is not an all-inclusive list of non-covered procedure codes. The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. Non-Covered Codes
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