CurrentAmbetter NevadaPolicy CP.MP.246

Pediatric Kidney Transplant Coverage Criteria

Medical necessity criteria for pediatric kidney transplantation for non-Medicare health plans affiliated with Centene (pediatric members <18), including indications, contraindications, and coding references.

Policy Summary

PayerAmbetter Nevada

PolicyPediatric Kidney Transplant Coverage Criteria

Policy CodePolicy CP.MP.246

Change TypeCriteria revision (GFR thresholdscontraindication clarifications)

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation demonstrating ESRD (GFR < 15) or CKD stage 4 (GFR < 30 if expected to reach ESRD) and absence of listed contraindications.

SourceLink

POLICY UPDATE CHANGES

Changed GFR threshold for ESRD criterion from ≤ 15 mL/min/1.73m2 to < 15 mL/min/1.73m2 to align with KDIGO and OPTN guidance.

Expanded stage 4 CKD criterion to include members with GFR < 30 mL/min/1.73m2 who are expected to reach end-stage renal disease (ESRD).

Updated contraindications (I.B) to be consistent with KDIGO guideline recommendations, including detailed HIV criteria (CD4, absence of opportunistic infection, on ART).

Age < 18Population covered (pediatric members)

GFR < 15ESRD threshold for transplant eligibility

GFR < 30CKD stage 4 threshold

10 itemsContraindication categories

Multiple codesCoding guidance included

Transplant Coverage Criteria

Initial transplant eligibility

Covered when ALL of the following are met:

Overall

A. Advanced renal disease: Member has one of: (1) End-stage renal disease (ESRD, stage 5) with GFR < 15 mL/min/1.73 m2; OR (2) Chronic kidney disease (CKD, stage 4) with GFR < 30 mL/min/1.73 m2 in members expected to reach ESRD.GFR thresholds as specified
Patients with GFR > 30 who are rapidly progressing toward ESRD should be referred for evaluation.
B. Contraindications absent
- Contraindications list: 1. Active infection that is not properly treated (except hepatitis C); 2. HIV infection with detectable viral load unless all of the following are documented: a) CD4 > 200 cells/mm3; b) absence of active AIDS-defining opportunistic infection; c) currently on effective antiretroviral therapy (ART); 3. Active malignancy with high risk of recurrence or death related to cancer; 4. Stroke within the past 6 months or transient ischemic attack within the past 3 months; 5. Active symptomatic cardiac disease (e.g., angina, arrhythmia, heart failure, valvular disease) that has not been evaluated by a cardiologist — cardiology clearance required after myocardial infarction; 6. Active symptomatic peripheral arterial disease not properly managed; 7. Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support; 8. Active or ongoing substance use disorder that affects decision-making or increases post-transplant risk; 9. Decompensated cirrhosis unless candidate for combined liver–kidney transplant; 10. Elevated circulating anti-glomerular basement membrane (anti-GBM) antibodies.

Policy Summary

PayerAmbetter Nevada

PolicyPediatric Kidney Transplant Coverage Criteria

Policy CodePolicy CP.MP.246

Change TypeCriteria revision (GFR thresholdscontraindication clarifications)

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation demonstrating ESRD (GFR < 15) or CKD stage 4 (GFR < 30 if expected to reach ESRD) and absence of listed contraindications.

SourceLink

On This Page

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See individual items for specific timeframes and lab cutoffs

Refer to policy for HIV-specific documentation and exceptions for hepatitis C.

Operational note: Prior authorization is required and clinical documentation must demonstrate the advanced renal disease criteria and absence (or remediation) of listed contraindications; HIV-positive candidates must document CD4 > 200 cells/mm3, absence of active AIDS-defining infection, and current effective ART.

See coding and prior authorization guidance for CPT/HCPCS codes to include in requests.

Coverage for pediatric kidney transplantation is excluded while the member has unresolved contraindications as listed in this policy. Key exclusions include active infection that is not properly treated (except hepatitis C), active malignancy with high risk of recurrence or death, recent cerebrovascular events (stroke within 6 months or TIA within 3 months), active symptomatic cardiac or peripheral arterial disease that has not been appropriately evaluated or managed, inability to adhere to the required post‑transplant regimen despite caregiver support, active substance use disorder that increases post‑transplant risk, decompensated cirrhosis unless the candidate is being considered for combined liver‑kidney transplant, and elevated circulating anti‑glomerular basement membrane antibodies.

Transplantation is not medically necessary when any of the explicit contraindications are present and cannot be remedied. Examples that will trigger denial include active untreated infection (except hepatitis C), HIV with detectable viral load without documented clearance criteria, active malignancy with high recurrence or mortality risk, recent stroke or TIA within the specified timeframes, active symptomatic cardiac disease without cardiology evaluation or clearance after myocardial infarction, unmanaged peripheral arterial disease, inability to adhere to the required regimen, ongoing substance use disorder that impairs decision‑making or increases post‑transplant risk, decompensated cirrhosis when not a combined‑organ candidate, and markedly elevated anti‑GBM antibodies.

Candidate Selection and Eligibility

Candidate selection — disease severity and contraindications

Candidate meets transplant eligibility when all disease severity and absence-of-contraindication criteria are met.

Candidate criteria

Disease severity: ESRD (stage 5) with GFR < 15 mL/min/1.73 m2 OR CKD (stage 4) with GFR < 30 mL/min/1.73 m2 in members expected to reach ESRD.GFR thresholds as specified
Rapidly progressing patients with GFR > 30 should be referred for evaluation.
Absence of contraindications
- Listed contraindications: 1) Active untreated infection (except HCV); 2) HIV with detectable viral load unless CD4 > 200 cells/mm3, absence of active AIDS-defining opportunistic infection, and on effective ART; 3) Active malignancy with high risk of recurrence or death; 4) Stroke within past 6 months or TIA within past 3 months; 5) Active symptomatic cardiac disease not evaluated by cardiology (cardiology clearance required after MI); 6) Active symptomatic peripheral arterial disease not properly managed; 7) Inability to adhere to required regimen despite caregiver support; 8) Active/ongoing substance use disorder affecting decision-making or increasing post-transplant risk; 9) Decompensated cirrhosis unless candidate for combined liver–kidney transplant; 10) Elevated circulating anti-GBM antibodies.See individual items for specifics
  Documentation should demonstrate remediation or absence of these contraindications prior to approval.

HIV-specific documentation: For HIV-positive candidates, document CD4 > 200 cells/mm3, absence of active AIDS-defining opportunistic infection, and that the member is receiving effective ART.CD4 > 200 cells/mm3

If these are not met, transplant is contraindicated until criteria are satisfied.

Contraindications and Exclusions

Detailed contraindications that must be absent or resolved prior to listing or transplantation include: active infection that is not properly treated (except hepatitis C); HIV infection with detectable viral load unless all three of the following are documented: CD4 cell count > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and the member is currently on effective antiretroviral therapy (ART); active malignancy with high risk of recurrence or death; stroke within the past 6 months or transient ischemic attack within the past 3 months; active symptomatic cardiac disease (e.g., angina, arrhythmia, heart failure, valvular disease) that has not been evaluated by a cardiologist — and cardiology clearance is required after myocardial infarction; active symptomatic peripheral arterial disease that is not properly managed; inability to adhere to the regimen necessary to preserve the transplant even with caregiver support; active or ongoing substance use disorder that affects decision‑making or increases post‑transplant risk; decompensated cirrhosis unless the candidate is being considered for a combined liver‑kidney transplant; and elevated circulating anti‑glomerular basement membrane antibodies.

Pre-Transplant Evaluation Requirements

Prior Authorization

Multidisciplinary evaluation and cardiac assessment required

Perform a multidisciplinary transplant evaluation consistent with KDIGO and OPTN guidance; determine the cause of ESRD when possible and obtain cardiology evaluation for symptomatic cardiac disease or cardiology clearance after myocardial infarction.

Multidisciplinary evaluation per KDIGO and OPTN guidance.
Determine cause of ESRD where possible.
Cardiology evaluation for symptomatic cardiac disease; cardiology clearance required after MI.

Provider Actions and Prior Authorization

Prior Authorization

Prior authorization required; cite procedure codes

Request prior authorization per payer procedures for pediatric kidney transplantation and reference the listed CPT and HCPCS codes when submitting requests.

Include relevant clinical evidence demonstrating medical necessity with the PA request.
Reference procedure codes such as 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50360, 50365, 50547, and S2152 as applicable.

Step Therapy

No step therapy required

No step therapy requirements are specified in this policy; evaluation and coverage determination are based on meeting transplant medical necessity criteria and guideline-based evaluation.

Documentation Required

Required clinical documentation and HIV-specific requirements

Provide clinical documentation that demonstrates advanced renal disease per policy thresholds and absence of listed contraindications; for HIV-positive candidates include CD4 > 200, no active AIDS-defining opportunistic infection, and evidence of current effective ART.

Document ESRD with GFR < 15 mL/min/1.73m2 or CKD stage 4 with GFR < 30 mL/min/1.73m2 expected to progress to ESRD.
Document absence of listed contraindications (see policy).
For HIV: CD4 > 200 cells/mm3, absence of active AIDS-defining opportunistic infection, and current effective antiretroviral therapy.

Denial Risk

Active or unremediable contraindications can cause denial

Presence of any listed active or unremediable contraindication may render transplant not medically necessary and can lead to denial until resolved or managed per policy.

Active untreated infection (except hepatitis C) excludes coverage until treated.
Active malignancy with high recurrence/death risk, recent stroke/TIA within policy time windows, active symptomatic cardiac or peripheral arterial disease without appropriate evaluation/management, inability to adhere to required regimen, active substance use disorder, decompensated cirrhosis (unless candidate for combined liver-kidney), and elevated anti-GBM antibodies are examples of contraindications that may cause denial.

Coding and Billing References (Informational)

Referenced procedure codes (informational)CPT | HCPCS

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.

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GFR thresholds — ESRD and CKD stage 4

ESRD (stage 5) thresholdGFR < 15 mL/min/1.73m2

CKD stage 4 threshold (eligible if expected to progress)GFR < 30 mL/min/1.73m2 when expected to reach ESRD

Rapidly progressing patients referral notePatients with GFR > 30 mL/min/1.73m2 who are rapidly progressing toward ESRD should be referred for transplant evaluation

Definitions and Thresholds

ESRD (stage 5) — definition

Definition (ESRD, stage 5)End-stage renal disease defined as GFR < 15 mL/min/1.73m2

PopulationApplies to pediatric members/enrollees (age < 18)

Use in eligibility determinationMeets the advanced renal disease criterion for transplant candidacy when documented in clinical record

CKD stage 4 — eligibility criterion

CKD stage 4 numeric thresholdGFR < 30 mL/min/1.73m2

Eligibility conditionEligible for transplant evaluation if expected to reach ESRD

Referral notePatients with GFR above 30 who are rapidly progressing toward ESRD should be referred for evaluation

Center and Program Requirements

Note

Center must follow guideline-based evaluation; no explicit accreditation listed

Policy references guideline-based center evaluation but does not specify explicit center accreditation, minimum volume, or other institutional requirements in this document.

Follow guideline-based evaluation processes (KDIGO/OPTN) at the center.
No explicit accreditation or case-volume requirements are listed in this policy.

Post-Transplant Services and Global Procedure Coverage

Comprehensive transplant service — global and related procedure codes

Global comprehensive transplant codeS2152 — Solid organ(s) procurement, transplantation, and related complications; comprehensive global code covering procurement, transplantation, hospitalization, outpatient follow-up, drugs, supplies, and defined pre/posttransplant care

Donor nephrectomy (cadaver)50300 — Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral

Donor nephrectomy (living donor, open)50320 — Donor nephrectomy (including cold preservation); open, from living donor

Renal allotransplantation (implantation)50360 — Renal allotransplantation, implantation of graft; without recipient nephrectomy; 50365 — with recipient nephrectomy

Background and Rationale

Kidney transplantation is the preferred treatment for pediatric patients with advanced chronic kidney disease or end‑stage renal disease because it improves survival, quality of life, and supports normal growth and development. When feasible, preemptive transplantation (often from a living donor) is preferred. Candidate evaluation should be multidisciplinary and follow KDIGO and OPTN guidance, with efforts to identify the cause of ESRD and to optimize the child’s medical status prior to transplantation.