Clinical UM Guideline
|Guideline #:||CG-TRANS-02||Current Effective Date:||01/14/2014|
|Status:||Reviewed||Last Review Date:||11/14/2013|
A kidney transplant involves the removal of the kidney from a deceased or living donor with the implantation into a single recipient.
Note: Please see the following related transplant documents for additional information:
Note: Members must meet the clinical indications as well as the general individual selection criteria for the transplantation to be considered medically necessary.
Kidney transplantation from a deceased or a living donor is considered medically necessary for selected individuals with end stage renal disease. The clinical indications leading to end stage renal disease include, but are not limited to, one of the conditions listed below.
Polycystic kidney disease
Medullary cystic disease
Hemolytic uremic syndrome
Acute and subacute glomerulonephritis
Anaphylactoid purpura (Henoch-Schonlein)
Steroid-resistant nephrotic syndrome
Toxic nephropathy (including nephropathy related to cyclosporine/tacrolimus toxicity)
Chronic allograft nephropathy (i.e., chronic rejection)
Renal artery occlusion
Renal vein thrombosis
Polyarteritis (periarteritis nodosa)
Etiology unknown (documented chronic renal failure of at least 6-8 weeks duration)
Repeat transplant due to acute or chronic graft failure is considered medically necessary.
Simultaneous Liver Kidney Transplantation
Kidney transplant as part of a simultaneous liver-kidney (SLK) transplantation is considered medically necessary when criteria for liver transplantation are met and when one of the following are met:
Not Medically Necessary:
Kidney transplantation for conditions other than end stage renal disease is considered not medically necessary.
Kidney transplantation as part of a simultaneous liver kidney (SLK) transplant is considered not medically necessary, if one of the above SLK criteria are not met.
Note: For multi-organ transplant requests, criteria must be met for each organ requested. In those situations, an individual may present with a concurrent medical condition which may be considered an exclusion or a comorbidity that would preclude a successful outcome, but would be treated with the additional organ transplant. Such cases will be reviewed on an individual basis for coverage determination to assess the member's candidacy for transplantation.
General Individual Selection Criteria
In addition to having one of the clinical indications above, the member must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.*
Absolute Contraindications- for Transplant Recipients include, but are not limited to, the following:
*Steinman, Theodore, et al. Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation. Transplantation. 2001; (71)9:1189-1204.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|00868||Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient)|
|50300||Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral|
|50320||Donor nephrectomy (including cold preservation); open from living donor|
|50323||Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary|
|50325||Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary|
|50327||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each|
|50328||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each|
|50329||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each|
|50360||Renal allotransplantation, implantation of graft; without recipient nephrectomy|
|50365||Renal allotransplantation, implantation of graft; with recipient nephrectomy|
|50547||Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor|
|ICD-9 Procedure||[For dates of service prior to 10/01/2014]|
|55.69||Other kidney transplantation|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Procedure||[For dates of service on or after 10/01/2014]|
|0TY00Z0||Transplantation of right kidney, allogeneic, open approach|
|0TY00Z1||Transplantation of right kidney, syngeneic, open approach|
|0TY10Z0||Transplantation of left kidney, allogeneic, open approach|
|0TY10Z1||Transplantation of left kidney, syngeneic, open approach|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
Nearly 26 million Americans have chronic kidney disease (CKD), with 570,000 diagnosed with kidney failure known as end stage renal disease (ESRD) (CDC, 2010). In November of 2012, the Organ Procurement and Transplantation Network reported nearly 94,000 Americans were on the United States wait list for kidney transplantation with approximately 16,000 kidney transplants performed annually (OPTN, 2012).
A kidney transplant involves the surgical removal of a kidney from a deceased or living donor and implanted into a recipient. 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 uretero-ureteral anastomosis or ureteropyelostomy may be performed.
Hepatorenal syndrome is a severe complication of liver cirrhosis or other severe liver disease. Features of hepatorenal syndrome are renal dysfunction caused by abnormalities in the arterial circulation and the vasoactive systems, resulting in renal vasoconstriction and renal insufficiency. There are two types of hepatorenal syndrome. Type I hepatorenal syndrome occurs when renal function is rapidly reduced and has an ominous prognosis which is usually reversed by liver transplantation. Type II hepatorenal syndrome occurs when renal failure does not progress rapidly. It can be quite difficult to distinguish these two conditions in individuals with severe liver disease. Liver transplantation is the recognized treatment for hepatorenal syndrome (Davis, 2005; Marik, 2006).
Concern has been raised since the introduction of the MELD (model for end-stage liver disease) prioritization for liver transplant that some recipients that undergo combined liver and kidney transplantation may have reversible renal failure. To address this issue, the American Society of Transplantation and American Society of Transplant Surgeons met in March 2006 to review post-MELD data on the impact of renal function on liver waitlist and transplant outcomes and the result of simultaneous liver kidney transplantation. This committee issued a consensus statement with regard to simultaneous liver-kidney (SLK) transplantation summarized below (Davis, 2007):
There is a paucity of large prospective randomized controlled trials in the peer reviewed literature to support the use of combined kidney liver transplantation when the duration of renal failure and dialysis is less than six weeks.
Allotransplantation: The transfer of cells, tissues, or whole organs from one individual to another within the same species.
Chronic Renal Disease: The permanent loss of kidney function.
End Stage Renal Disease (ESRD): Persistent decline in renal function as documented by falling creatinine clearance in an individual diagnosed with a renal disease whose natural history is progression to renal impairment requiring renal replacement (dialysis or transplant).
Nephropathy: Refers to damage or disease of the kidney.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||11/14/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion, References and Websites.|
|Reviewed||11/08/2012||MPTAC review. Updated Discussion, References and Websites.|
|Reviewed||11/17/2011||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References, Coding and Websites.|
|Revised||11/18/2010||MPTAC review. Clarified Simultaneous Liver Kidney Transplantation medically necessary clinical indication criteria. Updated References and Websites.|
|Reviewed||11/19/2009||MPTAC review. Place of service removed and references updated.|
|Reviewed||11/20/2008||MPTAC review. Clarified not medically necessary statement for kidney transplantation as part of a simultaneous liver kidney transplant. References updated|
|Revised||11/29/2007||MPTAC review. Added kidney transplantation as part of a simultaneous liver kidney transplant is considered not medically necessary, if any of the above clinical criteria are not met.|
|Reviewed||08/23/2007||MPTAC review. References updated.|
|New||09/14/2006||MPTAC review. Document TRANS.00032 converted into a clinical UM guideline.|
|Reviewed||03/23/2006||MPTAC review. Definitions added. References updated.|
|Revised||04/28/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||Archived||TRANS.00007H||Kidney Transplant|
|WellPoint Health Networks, Inc.||09/23/2004||7.08.01||Kidney Transplantation|