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Pancreas transplantation occurs in several different scenarios such as: 1) a type 1 diabetic patient with renal failure who may receive a cadaveric simultaneous pancreas/kidney transplant (SPK); 2) a type 1 diabetic patient who may receive a cadaveric or living-related pancreas transplant after a kidney transplantation (pancreas after kidney, i.e., PAK); or 3) a non-uremic type 1 diabetic patient with specific severely disabling and potentially life-threatening diabetic problems who may receive a pancreas transplant alone (PTA). The experience with SPK transplants is more extensive than that of other transplant options. 

The approach to retransplantation varies according to the cause of failure. Surgical/technical complications such as venous thrombosis are the leading cause of pancreatic graft loss among diabetic patients. Graft loss from chronic rejection may result in sensitization, increasing both the difficulty of finding a cross-matched donor and the risk of rejection of a subsequent transplant.

The total number of pancreas transplants peaked at 1,484 in 2004; the number has since annually declined. In 2010, 265 adults and 36 children received PTA transplants in the U.S. There were 1,413 patients on this waiting list at the end of 2010. The 5-year patient survival is 89%; graft survival is considerably lower at 52%. Survival statistics for PAK are similar. Also in 2010, 700 adults and 4 children received SPK transplants. There were 2,217 patients on this waiting list at the end of 2010. The 5-year patient survival for this group is 87%; graft survival is 78% for the kidney and 72% for the pancreas.

A combined pancreas-kidney transplant may be considered medically necessary in insulin dependent diabetic patients with uremia.

Pancreas transplant after a prior kidney transplant may be considered medically necessary in patients with insulin dependent diabetes mellitus.

Pancreas transplant alone may be considered medically necessary in 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.

Pancreas retransplant after a failed primary pancreas transplant may be considered medically necessary.

The determination will be made through the peer review process (which includes, but is not limited to the review of peer reviewed literature, second opinions and administrative policy in existence at the time of the request for the procedure).

Pancreas Specific

Candidates for pancreas transplant alone should additionally meet 1 of the following severity of illness criteria:

• Documentation of severe hypoglycemia unawareness as evidenced by chart notes or emergency room visits; OR
• Documentation of potentially life-threatening labile diabetes as evidenced by chart notes or hospitalization for diabetic ketoacidosis.

In addition, the vast majority of pancreas transplant patients will have type 1 diabetes mellitus. Those transplant candidates with type 2 diabetes mellitus, in addition to being insulin-dependent, should also not be obese (body mass index [BMI] should be 32 or less).

Multiple Transplants

Although there are no standard guidelines regarding multiple pancreas transplants, the following information may aid in case review:

• If there is early graft loss resulting from technical factors (e.g., venous thrombosis), a retransplant may generally be performed without substantial additional risk.
• Long-term graft losses may result from chronic rejection, which is associated with increased risk of infection following long-term immunosuppression, and sensitization, which increases the difficulty of finding a negative cross-match. Some transplant centers may wait to allow reconstitution of the immune system before initiating retransplant with an augmented immunosuppression protocol.

Investigative 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.

2/14/2002: Investigational definition added, table added to Code Reference section

5/2/2002: Type of Service and Place of Service deleted

10/18/2005:  Policy section updated; "Absence of HIV infection" deleted; added "HIV positivity is not an absolute contraindication to transplant. Each individual transplant center will determine patient selection criteria for HIV positive patients (7/21/2005)"; Code Reference table updated: CPT codes 48551, 48552, 48556 added; ICD-9 procedure code 00.93 added; HCPCS codes S2065, S2152 added; diagnosis codes 250-250.92, V58.67 added, 250.11, 250.13, 250.21, 250.23, 250.31, 250.41, 250.43, 250.51, 250.61, 250.63, 250.71, 250.73, 250.81, 250.83, 251.0, 251.1, 251.2 deleted.

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

3/13/2006:  Coding updated.  CPT4/HCPCS 2006 revisions added to policy

10/23/2006: Policy reviewed, policy section re-written for clarity

2/22/2008: Removed the following policy statement: "Pancreas retransplant after 2 or more prior failed pancreas transplants is considered investigational." No other changes made to policy statements. Code Reference section reviewed. Removed ICD-9 codes 250.00, 250.02, 250.50, 250.52, 250.60, 250.62, 250.70, and 250.72. Added ICD-9 codes 250.11, 250.13, 250.21, 250.23, 250.31, 250.33, 250.41, 250.43, 250.81, 250.83, 250.91, 250.93, and 996.86. "Allogeneic" added to policy title

12/31/2008: Policy reviewed, prior authorization for evaluation removed.

05/09/2011: Policy description updated regarding the number and success of pancreas tranplants. "Insulin dependent" added to the first policy statement. Policy statement added to state when pancreas transplant is considered not medically necessary. Policy guidelines updated regarding candidates for pancreas transplant.

05/08/2012: Deleted the not medically necessary policy statement, which stated the following: Pancreas transplant is considered not medically necessary in patients with the following conditions: 1.  Known current malignancy, including metastatic cancer; 2.  Recent malignancy with high risk of recurrence; 3.  Untreated systemic infection making immunosuppression unsafe, including chronic infection; or 4. Other irreversible end-stage disease not attributed to kidney or pancreatic disease. "Insulin dependent" added to the third policy statement. Policy guidelines updated regarding contraindications to tranplant.

04/16/2013: Policy reviewed; no changes.

Hayes Medical Technology Directory

Blue Cross Blue Shield Association policy #7.03.02

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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