Pancreas Transplantation
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Clinical policy governing medical necessity and coverage considerations for pancreas transplantation for members of Arizona Complete Health; includes candidate selection, contraindications, and coding updates referenced in the document.
Changed 'myocardial infarction within 30 days' to 'myocardial (within 6 months)' and reworded stroke/acute coronary syndrome information.
Specified 'type I' under criteria I.A.1 and clarified several wording items (e.g., 'require' → 'required').
Coverage and Medical Necessity Criteria
Updated/clarified eligibility and exclusion criteria (partial)
Policy criteria updates and clarifications (partial extract from document):
Applied to candidate selection
Used in assessing recent cardiac events as part of contraindications/eligibility
Indication for pancreas transplantation consideration
Affects combined kidney-pancreas candidacy or listing
Criterion involving medication dosing
Contraindications for pancreas transplantation have been reorganized in this policy and were moved from section I.B to I.C. The excerpt does not list the full set of absolute or relative contraindications; providers should refer to the complete policy for the detailed contraindication list when assessing candidate eligibility. The document revision note explicitly records that contraindications were relocated to I.C, but the specific entries under that heading are not included in this excerpt.
This coverage criteria section references additional items and clarifications that are not fully reproduced in the excerpt. Notable updates called out in the revision note include specification of type I diabetes under criterion I.A.1, addition of ‘or dialysis dependent’ to I.B.2.c, and a medication dose threshold added in I.B.3.c.ii specified as greater than 500 mg/day. The full policy contains the complete wording and any additional criteria referenced here; consult the full document for operational use.
Candidate Selection and Eligibility
Candidate selection updates (partial)
Partial candidate criteria updates present in this excerpt:
Restricts pancreas transplant candidacy to type I in that criterion
Indication for transplant
Contraindications
The policy states that contraindications have been moved from section I.B to I.C during the latest revision. The excerpt does not provide the specific contraindications now listed under I.C, so clinicians should consult the full policy text to determine which conditions are considered absolute or relative contraindications for pancreas transplantation following the reorganization.
Billing and Coding
| 50328 | CPT code added to pancreas transplantation policy |
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required for pancreas transplantation. CPT code 50328 has been added to the billing/coding set — ensure prior authorization requests include this code when applicable.
- Prior authorization required — include CPT 50328 when applicable.
Documentation Must Reflect Updated Clinical Criteria
Documentation must explicitly reflect the updated clinical criteria. Medical records and authorization submissions should specify diabetes type (e.g., type I diabetes) where required, document timing for recent cardiac events using the revised timeframe (e.g., myocardial infarction within 6 months), and note recurrent severe hypoglycemic attacks when cited in criteria.
- Specify diabetes type (type I) where required.
- Document myocardial infarction timing using the updated 6‑month window.
- Document recurrence and details of severe hypoglycemic attacks when applicable.
Provider Action — Update Templates and Submissions
Providers should review the revised clinical criteria and update their internal workflows and documentation templates accordingly to avoid denials or delays. Ensure that any prior authorization submissions reference the updated criteria and supporting documentation (e.g., dialysis dependence, insulin requirements >500 mg/day where specified).
- Update clinical documentation templates to capture: diabetes type, timing of MI/stroke/acute coronary syndrome, dialysis dependence when relevant, and insulin dosing thresholds (>500 mg/day where applicable).
- Reference updated criteria in prior authorization submissions to reduce denial risk.
Definitions
Pre-Transplant Evaluation Requirements
Follow updated pretransplant evaluation guidance (referenced: UpToDate)
Providers should follow the updated references for pretransplant evaluation (the policy references UpToDate) when performing evaluations; although specific evaluation steps are not detailed in this excerpt, use the referenced guidance to complete pretransplant assessments.
- Consult the policy references (e.g., UpToDate) for current pretransplant evaluation guidance
- Document that evaluation followed accepted pretransplant reference materials
Center and Program Requirements
Align center procedures with OPTN and CMS guidance
Ensure transplant center processes and requirements align with national guidance referenced in the policy (OPTN and CMS); the policy notes alignment with these sources though specific center-level requirements are not present in this excerpt.
- Verify center policies and reporting conform with OPTN and CMS expectations referenced in the policy
- Document center-level compliance with applicable OPTN/CMS requirements when requested
Post-Transplant Coverage and Follow-up
Background and References
Background references for this policy were updated and now cite established sources used in transplant candidate evaluation and follow-up (for example, UpToDate, the American Diabetes Association, OPTN, and CMS) as part of the document review. The excerpt notes that background material was updated during the revision and that the policy was reviewed by internal and external specialists, but the full background narrative and citations are not included in this excerpt; consult the full policy for the complete background and reference list.
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