Medical Policy Kidney Transplant

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1 Medical Policy Kidney Transplant Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 196 BCBSA Reference Number: Related Policies Allogeneic Pancreas Transplant, #615 Plasma Exchange, #466 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO Blue SM and Medicare PPO Blue SM Members Renal (kidney) transplantation may be MEDICALLY NECESSARY for patients with end-stage renal disease AND for those patients with no contraindications who are diagnosed with any of the following conditions, including but not limited to: Diabetes mellitus Hypertensive nephrosclerosis Acute tubular necrosis Glomerulonephritis Lupus (SLE) Goodpasture's (Anti-glomerular base-membrane disease) Polyarteritis Wegener's granulomatosis Henoch-Schönlein purpura Hemolytic uremic syndrome IGA nephropathy Nephritis Focal glomerulosclerosis Cortical necrosis Analgesic nephropathy with medullary necrosis Heavy metal poisoning Medullary cystic disease Nephrocalcinosis Gout nephritis Amyloid disease Fabry's disease Cystinosis or Oxalosis 1

2 Renal artery or vein occlusion Chronic pyelonephritis Obstructive uropathy Tuberous sclerosis Polycystic kidney disease Horseshoe kidney or Renal aplasia or hypoplasia Myeloma (no remission or in remission) Wilms tumor or Renal-cell carcinoma, or Trauma requiring nephrectomy injury to kidney. Kidney retransplant after a failed primary kidney transplant may be MEDICALLY NECESSARY. Renal (kidney) transplantation in patients with the following conditions is NOT MEDICALLY NECESSARY: History of malignancy with evidence of metastatic disease, High probability of malignancy recurrence in the absence of metastatic disease (Exception: For renal cell cancers of less than 5 cm discovered incidentally, a waiting period of 2 years is recommended), Presence of active infection, Inability to comply with medical management, and Inadequate cardiopulmonary status. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Commercial Members: PPO, and Indemnity Medicare Members: HMO Blue SM Medicare Members: PPO Blue SM CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description Donor nephrectomy, (including cold preservation); from cadaver donor, unilateral or bilateral Donor nephrectomy, (including cold preservation); open, from living donor 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), 2

3 renal vein(s), and renal artery(s), ligating branches, as necessary 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 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each Recipient nephrectomy Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description Malignant neoplasm of kidney, except pelvis Multiple myeloma, without mention of having achieved remission Multiple myeloma, in remission Multiple myeloma, in relapse Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified Secondary diabetes mellitus with renal manifestations, uncontrolled Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with renal manifestations, type II or unspecified type, uncontrolled Diabetes with renal manifestations, type I [juvenile type], uncontrolled Lipidoses Gouty nephropathy, unspecified Other gouty nephropathy Other disorders of calcium metabolism Amyloidosis, unspecified Other amyloidosis Hemolytic-uremic syndrome Allergic purpura Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Polyarteritis nodosa Goodpasture's syndrome Wegener's granulomatosis Other venous embolism and thrombosis of renal vein Nephrotic syndrome in diseases classified elsewhere Chronic glomerulonephritis with lesion of membranous glomerulonephritis 3

4 Nephritis and nephropathy, not specified as acute or chronic, with lesion of renal cortical necrosis Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney Acute kidney failure with lesion of tubular necrosis Acute kidney failure with lesion of renal medullary [papillary] necrosis End stage renal disease Chronic pyelonephritis without lesion of renal medullary necrosis Vascular disorders of kidney Urinary obstruction, unspecified Urinary obstruction, not elsewhere classified Renal agenesis and dysgenesis Polycystic kidney, unspecified type Polycystic kidney, autosomal dominant Polycystic kidney, autosomal recessive Medullary cystic kidney Other specified anomalies of kidney Tuberous sclerosis Injury to kidney without mention of open wound into cavity, unspecified injury Injury to kidney without mention of open wound into cavity, hematoma without rupture of capsule Injury to kidney without mention of open wound into cavity, laceration Injury to kidney without mention of open wound into cavity, complete disruption of kidney parenchyma Injury to kidney with open wound into cavity, unspecified injury Injury to kidney with open wound into cavity, hematoma without rupture of capsule Injury to kidney with open wound into cavity, laceration Injury to kidney with open wound into cavity, complete disruption of kidney parenchyma Poisoning by other specified systemic agents ICD-9 Procedure Codes ICD-9-CM procedure codes: Code Description Transplant from live related donor Transplant from live non-related donor Transplant from cadaver Nephroureterectomy Bilateral nephrectomy Other kidney transplantation Description Renal (kidney) transplantation has become the treatment of choice for many patients with end-stage renal disease. Marked improvements in early graft survival and long-term graft function have translated into kidney transplantation being a more cost-effective alternative to dialysis. Across most age groups and etiologies of end-stage renal disease, studies show that renal transplantation prolongs patient lifespan relative to dialysis; therefore, patients on dialysis are increasingly being referred for transplant evaluation. A kidney transplant involves the surgical removal of a kidney from a cadaver, living-related, or unrelated donor and transplantation into the recipient. A resurgence of interest in living donation, stimulated by the introduction of laparoscopic living donor nephrectomy in 1994, has led to significantly increased numbers 4

5 of living donor transplants, which is also associated with improved outcomes and significantly shorter waiting periods. Combined kidney and pancreas transplantation is the treatment of choice for patients who have type 1 diabetes and end-stage renal disease. Candidates for this combined procedure are typically younger than 50 years and do not have significant coronary artery disease. Summary Kidney transplant is an accepted treatment of end-stage renal disease in appropriately selected patients and thus may be considered medically necessary. Registry and national survey data suggest that live donors of kidneys for transplantation do not have an increased risk of mortality or ESRD. Kidney retransplantation after a failed primary transplant may be considered medically necessary, as national data suggest similar survival rates after initial and repeat transplants. Kidney transplantation is not medically necessary in patients in whom the procedure is expected to be futile due to comorbid disease or in whom post-transplantation care is expected to significantly worsen comorbid conditions. Case series and case-control data indicate that HIV-infection is not an absolute contraindication to kidney transplant; for patients who meet selection criteria, these studies have demonstrated patient and graft survival rates are similar to those in the general population of kidney transplant recipients. Policy History Date Action 11/2013 BCBSA National medical policy review. New medically necessary indications described. Effective 11/1/ /2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/ /2011 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplants. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplants. 6/2010 Reviewed following local input Revised policy statement 11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplants. 11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplants. 11/2007 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplants. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. U.S. Department of Health and Human Services Organ Procurement and Transplantation Network. Available online at: Last accessed April,

6 2. Shrestha BM. Strategies for reducing the renal transplant waiting list: a review. Exp Clin Transplant 2009; 7(3): Schold JD, Segev DL. Increasing the pool of deceased donor organs for kidney transplantation. Nat Rev Nephrol 2012; 8(6): Segev DL, Muzaale AD, Caffo BS et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303(10): Fournier C, Pallet N, Cherqaoui Z et al. Very long-term follow-up of living kidney donors. Transpl Int 2012; 25(4): Steinman TI, Becker BN, Frost AE et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation 2001; 71(9): Trullas JC, Cofan F, Tuset M et al. Renal transplantation in HIV-infected patients: 2010 update. Kidney Int 2011; 79(8): Stock PG, Barin B, Murphy B et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010; 363(21): Mazuecos A, Fernandez A, Andres A et al. HIV infection and renal transplantation. Nephrol Dial Transplant 2011; 26(4): Organ Procurement and Transplantation Network. Data reports. Available online at: Last accessed April, Barocci S, Valente U, Fontana I et al. Long-term outcome on kidney retransplantation: a review of 100 cases from a single center. Transplant Proc 2009; 41(4): Johnston O, Rose CL, Gill JS et al. Risks and benefits of preemptive second kidney transplantation. Transplantation 2013; 95(5): Bhagani S, Sweny P, Brook G. British H. I. V. Association Guidelines for kidney transplantation in patients with H. I. V. disease. HIV Med 2006; 7(3): Medicare Benefit Policy Manual. Chapter 11- End Stage Renal Disease (ESRD). Available online at: Last accessed April,

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