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    v1.0.28
    OpenPayerPolicy UpdatesTransplantAmbetter Georgia pediatric kidney transplant Cover…
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    CurrentAmbetter GeorgiaPolicy CP.MP.246

    Pediatric Kidney Transplant

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    Medical necessity criteria and coding guidance for pediatric (<18 years) kidney transplantation for non‑Medicare Ambetter Georgia members/enrollees, based on KDIGO and OPTN guidance.

    Policy Summary
    PayerAmbetter Georgia
    PolicyPediatric Kidney Transplant
    Policy CodePolicy CP.MP.246
    Change TypeRevised clinical thresholds and clarified contraindications
    Effective DateJun 1, 2026
    Next Review Date
    Key ActionObtain prior authorization and submit documentation supporting GFR, transplant evaluation clearance, and specialist clearances as required.
    SourceLink
    POLICY UPDATE CHANGES

    Updated Criteria I.A.1. from GFR ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with KDIGO and OPTN guidance.

    Updated Criteria I.A.2. to include CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach ESRD.

    Updated contraindication I.B.2 to add detailed HIV-related clearance requirements (CD4 >200, absence of AIDS-defining infection, on effective ART).

    Age <18applies to pediatric members/enrollees
    GFR <15ESRD threshold
    GFR <30CKD stage 4 threshold

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    KDIGO/OPTNguideline sources

    Coverage Criteria

    Initial transplant eligibility (non-Medicare pediatric members)

    Covered when ALL of the following are met:

    Age: Member/enrollee is pediatric (age < 18)
    Advanced renal disease: Either: (1) End-stage renal disease (ESRD) with GFR < 15 mL/min/1.73m2 OR (2) CKD stage 4 with GFR < 30 mL/min/1.73m2 in members expected to reach ESRDGFR < 15 mL/min/1.73m2; GFR < 30 mL/min/1.73m2 for selected CKD stage 4

    Patients with GFR > 30 mL/min/1.73m2 who are rapidly progressing toward ESRD should be referred for transplant evaluation.

    Absence of contraindications: Candidate does not have any listed contraindications that preclude transplant (see contraindications block)

    Contraindications (must NOT be present)

    Transplant is NOT acceptable if ANY of the following active conditions exist unless specific exceptions apply:

    Infection: Active infection that is not properly treated (except hepatitis C virus infection)

    Hepatitis C is not an absolute contraindication per cited guidance

    HIV infection with detectable viral load, unless ALL of the following are documented: a) CD4 cell count > 200 cells/mm3; b) absence of active AIDS-defining opportunistic infection; c) member is currently on effective antiretroviral therapy (ART)CD4 > 200 cells/mm3

    If these HIV control criteria are met, HIV is not an absolute contraindication

    Malignancy: Active malignancy with high risk of recurrence or death related to cancer
    Recent cerebrovascular event: Stroke within the past six months or transient ischemic attack within the past three months
    Cardiac disease:

    Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Refer to the applicable state Medicaid manual for any specific coverage provisions that apply to this policy.

    Transplant is not medically necessary for members who do not meet the stated GFR thresholds (see eligibility criteria: GFR < 15 mL/min/1.73m2 for ESRD or selected CKD stage 4 with GFR < 30 mL/min/1.73m2 when expected to progress to ESRD) or who have any of the listed active contraindications that preclude transplantation.

    Candidate Evaluation and Selection

    General candidate evaluation

    Candidate selection considerations

    Multidisciplinary evaluation: Multidisciplinary team assessment including determination of the cause of ESRD when possible

    Preemptive transplantation from a living donor is preferred when appropriate

    Contraindications

    Transplant is contraindicated when any of the following active conditions are present unless specified exceptions apply: active untreated infection (except hepatitis C virus infection); HIV infection with detectable viral load unless documented evidence shows CD4 cell count > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and the member is on effective antiretroviral therapy; active malignancy with high risk of recurrence or cancer‑related death; stroke within the past six months or transient ischemic attack within the past three months; active symptomatic cardiac disease un‑evaluated by a cardiologist (cardiology clearance is required after myocardial infarction); active symptomatic peripheral arterial disease not properly managed; inability to adhere to required post‑transplant regimen even with caregiver support; active substance use disorder that increases post‑transplant risk; decompensated cirrhosis unless candidate for combined liver‑kidney transplant; and elevated circulating anti‑glomerular basement membrane antibodies.

    Evaluation and Clearance Requirements

    Documentation Required

    Evaluation requirements: cardiology clearance and multidisciplinary assessment

    Ensure cardiology clearance is obtained and documented for any candidate with a history of myocardial infarction; perform and document a multidisciplinary evaluation and attempt to determine the cause of ESRD as recommended by KDIGO guidance referenced in the policy.

    • Cardiology clearance required prior to transplant for members with prior myocardial infarction.
    • Multidisciplinary team assessment and documentation of transplant evaluation.
    • Documentation of efforts to determine cause of ESRD when possible (per KDIGO recommendations).

    Provider Actions and Requirements

    Prior Authorization

    Prior authorization required for listed transplant procedure codes

    Submit prior authorization for pediatric kidney transplant procedures and related services that reference the listed CPT and HCPCS codes; inclusion of codes is informational and does not guarantee coverage.

    • Referenced CPT codes: 50300, 50320, 50323, 50327, 50328, 50329, 50360, 50365, 50547.
    • Referenced HCPCS code: S2152.
    Note

    Follow provider instructions included in policy header

    Make sure any additional provider instructions included with the request are followed exactly as the policy text requires.

    Documentation Required

    Provide complete clinical and specialist documentation with PA request

    Coding and Billing

    Referenced CPT CodesCPT
    50300Donor nephrectomy (including cold preservation); from cadaver donor
    50320Donor nephrectomy (including cold preservation); unilateral or bilateral; open, from living donor
    50323Donor nephrectomy (including cold preservation); open, from living donor (Backbench standard preparation of donor renal allograft prior to transplantation)
    50327Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
    50328Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each
    50329Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each
    50360Renal allotransplantation, implantation of graft; without recipient nephrectomy
    50365Renal allotransplantation, implantation of graft; with recipient nephrectomy
    50547Laparoscopy, surgical; donor nephrectomy (including cold preservation), from
    Referenced HCPCS CodesHCPCS
    S2152Solid organ(s) procurement and transplantation global HCPCS (includes procurement, transplantation, related complications, drugs, supplies, hospitalization, outpatient follow-up, and pre- and post‑transplant care in the global definition)
    GFR thresholds
    ESRD threshold (most actionable)GFR < 15 mL/min/1.73m2 (End‑stage renal disease; stage 5)
    CKD stage 4 thresholdGFR < 30 mL/min/1.73m2 for candidates expected to progress to ESRD
    Referral notePatients with GFR > 30 mL/min/1.73m2 who are rapidly progressing toward ESRD should be referred for transplant evaluation

    Post-Transplant Coverage

    Global procurement and transplant services (HCPCS S2152)
    HCPCS S2152 description (most actionable)Solid organ(s) procurement and transplantation global: includes drugs, supplies, hospitalization with outpatient follow‑up, medical/surgical/diagnostic/emergency/rehabilitative services, and the number of days of pre‑ and post‑transplant care in the global definition
    Scope of bundleCovers procurement, transplantation, and related complications (deceased or living donors, single or combination organs)
    Included care elementsSpecifically names drugs, supplies, hospitalization, outpatient follow‑up, and rehabilitative services as part of the global bundle

    Center Requirements

    Note

    No explicit center accreditation or volume requirements stated

    The policy does not specify any center certification, FACT accreditation, or minimum procedural volume requirements for transplant centers.

    Definitions

    ESRD definition
    Definition of ESRD (most actionable)End‑stage renal disease (ESRD) is defined as GFR < 15 mL/min/1.73m2
    ContextESRD corresponds to stage 5 advanced renal disease in the policy criteria
    Policy alignmentThreshold wording updated from '≤ 15' to '< 15' to align with KDIGO and OPTN guidance (policy revision note)
    CKD stage 4 definition
    CKD stage 4 threshold (most actionable)Chronic kidney disease (stage 4) defined as GFR < 30 mL/min/1.73m2 for candidates expected to reach ESRD
    ApplicationApplies to selected pediatric candidates expected to progress to ESRD — included as alternative eligibility to ESRD for transplant consideration

    Background

    Kidney transplantation is the preferred treatment for pediatric advanced chronic kidney disease and end‑stage renal disease because it improves survival, quality of life, and growth—particularly in young children. When feasible, preemptive transplantation from a living donor is preferred. Candidate selection should involve a multidisciplinary evaluation and determination of the cause of ESRD when possible to inform timing and suitability for transplant.

    Revision History

    2026-06-01policy_effectiveLatest

    Policy updated to align GFR punctuation with KDIGO/OPTN guidance (GFR ≤ 15 changed to GFR < 15) and expanded eligibility to include selected CKD stage 4 members with GFR < 30 expected to progress to ESRD; contraindications updated to align with KDIGO.

    2024-04contraindication_clarification

    Contraindication I.B.2 (HIV) was updated to specify clearance criteria: CD4 > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and current effective antiretroviral therapy.

    2023-08
    Policy Summary
    PayerAmbetter Georgia
    PolicyPediatric Kidney Transplant
    Policy CodePolicy CP.MP.246
    Change TypeRevised clinical thresholds and clarified contraindications
    Effective DateJun 1, 2026
    Next Review Date
    Key ActionObtain prior authorization and submit documentation supporting GFR, transplant evaluation clearance, and specialist clearances as required.
    SourceLink
    On This Page
    Coverage CriteriaCandidate Evaluation and SelectionContraindicationsEvaluation and Clearance RequirementsProvider Actions and RequirementsCoding and BillingPost-Transplant CoverageCenter RequirementsDefinitionsBackgroundRevision History
    Active symptomatic cardiac disease (e.g., angina, arrhythmia, heart failure, valvular disease) that has not been evaluated by a cardiologist; if myocardial infarction, cardiology clearance required prior to transplant

    Cardiology evaluation and clearance required for recent MI

    Peripheral arterial disease: Active symptomatic peripheral arterial disease not properly managed
    Adherence: Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support
    Substance use: Active or ongoing substance use disorder that affects decision-making or places the member at high post-transplant risk
    Cirrhosis: Decompensated cirrhosis unless candidate for combined liver–kidney transplant
    Anti-GBM antibodies: Elevated levels of circulating anti-glomerular basement membrane antibodies

    Include documentation that supports the diagnosis and stage of CKD/ESRD, documented GFR values, transplant evaluation clearance, and any required specialist clearances (for example, cardiology clearance after myocardial infarction).

    • Document GFR values demonstrating GFR < 15 mL/min/1.73m2 (ESRD) or GFR < 30 mL/min/1.73m2 when expected to reach ESRD.
    • Include transplant evaluation notes showing multidisciplinary assessment and determination of ESRD cause when available.
    • Attach specialist clearance documentation (e.g., cardiology clearance after MI).
    Denial Risk

    Denial risks for age, GFR thresholds, and active contraindications

    Requests may be denied if the member is age 18 or older or when clinical criteria are unmet (for example, GFR thresholds not met) or if any active contraindications listed in the policy are present.

    • Denial may occur when member is age ≥ 18 (policy applies to pediatric members age < 18).
    • Denial may occur if GFR is not below the stated thresholds (GFR ≥ 15 mL/min/1.73m2 for ESRD or >30 mL/min/1.73m2 without expectation to reach ESRD).
    • Denial may occur if any listed active contraindications exist (e.g., untreated active infection, uncontrolled HIV, active malignancy, recent stroke/TIA, active symptomatic cardiac disease without cardiology evaluation).
    Policy updateCriterion added to align with KDIGO and OPTN guidance (policy revision note)
    criteria_revision

    Criteria I.A.1 punctuation changed from '≤ 15 mL/min/1.73m2' to ' < 15 mL/min/1.73m2' and Criteria I.A.2 expanded to include CKD stage 4 with GFR < 30 mL/min/1.73m2 expected to reach ESRD; non‑Medicare clarification and Medicare cross‑reference added.