CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Adrenal-to-Brain Transplantation

This policy governs coverage for adrenal medullary tissue transplantation into the brain (autograft or fetal allograft) for treatment of Parkinson's disease and indicates coverage stance for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdrenal-to-Brain Transplantation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 2, 2010

Next Review DateFeb 18, 2026

Key ActionSubmit claims for adrenal-to-brain transplantation (S2103) knowing they will be denied or considered not medically necessary per product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not covered / NMNCoverage stance (MA / Commercial)

1 codeCoding entries listed

AAN 1999; AHRQ 2003Evidence sources

No prior authAdmin requirements

Coverage Criteria

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Medicare Advantage: Adrenal-to-brain transplantation (autograft or fetal allograft) is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products: Adrenal-to-brain transplantation (autograft or fetal allograft) is considered not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

For Commercial Products, adrenal-to-brain transplantation using either an autograft or a fetal allograft is considered not medically necessary. The policy states the reason as insufficient evidence to determine the effects of the procedure on health outcomes. The corresponding procedure code is S2103, which is listed as not medically necessary for Commercial Products.

Provider Actions & Administrative Requirements

Prior Authorization

Not applicable.

Documentation Required

Administrative Requirement

Provider-facing operational note: refer to provider requirements and directions for submitting documentation to BCBSRI when applicable.

Documentation Required

Benefits and Documentation

Benefits may vary between groups/contracts. For applicable coverage determinations, refer to the appropriate Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement. This medical policy does not override the member's contract; benefits and eligibility are determined by the member's subscriber agreement or member certificate and those documents will supersede the provisions of this medical policy. For member-specific benefits, contact the provider call center.

Denial Risk

Coverage Denial Risk

Claims for adrenal-to-brain transplantation (S2103) will be denied or considered not medically necessary for Medicare Advantage and Commercial products: Medicare Advantage — not covered; Commercial — not medically necessary. The evidence is insufficient to determine the effects of the technology on health outcomes.

Medicare Advantage: adrenal-to-brain transplantation with autograft or fetal allograft — not covered
Commercial Products: adrenal-to-brain transplantation with autograft or fetal allograft — not medically necessary
Affected code example: S2103

Background

Adrenal-to-brain transplantation involves implanting adrenal medullary tissue into the corpus striatum (for example, the caudate nucleus or putamen) with the intent of restoring striatal dopamine and improving the motor and postural symptoms of Parkinson disease. Techniques described in the literature include autotransplantation (simultaneous adrenalectomy and craniotomy with implantation of the patient’s own adrenal medullary tissue) and fetal allografting (implantation of adrenal tissue harvested from a fetus). Implantation methods reported include open microsurgical and stereotactic approaches, and tissue is often placed in fragments exposed to cerebrospinal fluid. Published evidence is limited, and prior reviews and specialty guidance have not demonstrated sufficient efficacy or safety to support coverage; consequently the policy lists the procedure code S2103 as not covered or not medically necessary depending on product.

Definitions

Autotransplantation — definition and procedural description

TermAutotransplantation

Procedural descriptionAdrenal tissue is typically implanted in fragments at the margin of the lateral ventricle so tissue is exposed to cerebrospinal fluid; fragments may be anchored with surgical staples or Gelfoam; insertion can be via open microsurgical approach or stereotactic cannula-based implantation.

Allografting (fetal allograft) — definition and procedural description

TermAllografting (fetal allograft)

Procedural noteImplantation sites and methods mirror autotransplantation (caudate nucleus or putamen; open microsurgical or stereotactic implantation).