CurrentCapital BluecrossPolicy MP 9.005

Kidney Transplants, Pancreas Transplants, and Simultaneous Kidney/Pancreas Transplants

Medical necessity and coverage guidance for kidney transplants, pancreas transplants, and simultaneous kidney/pancreas transplants, including retransplantation and basic listing/contraindication guidance for Capital BlueCross products.

Policy Summary

PayerCapital Bluecross

PolicyKidney Transplants, Pancreas Transplants, and Simultaneous Kidney/Pancreas Transplants

Policy CodePolicy MP 9.005

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument renal function trajectory (dates of GFR ≤20 mL/min or dialysis initiation) and other evaluation information when requesting transplant listing or coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

27,759kidney transplants performed in 2024

48,149total transplants in US (2024)

87%–96%kidney retransplant 5-yr survival

MP 9.005Policy identifier

Coverage Criteria for Kidney and Pancreas Transplants

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Kidney and pancreas transplants may be considered medically necessary when the following criteria are met. Transplants not meeting these criteria are considered investigational or contraindicated as noted.

Kidney Transplant (Initial and Retransplant)

Candidate and Indication
- End-stage renal disease (ESRD) in a carefully selected candidate for kidney transplantation.
- Failed prior kidney transplant in an individual who otherwise meets criteria for kidney transplantation (retransplant).
Contraindications and Futility
- No medical contraindications that would make the procedure futile due to comorbid disease or where post-transplant care would significantly worsen comorbid conditions.
  Assessments should document evaluation of comorbidities and anticipated postoperative care needs.
Kidney transplant may be performed with either living or deceased (cadaveric) donor sources.

Pancreas transplants (alone, after kidney, or simultaneous pancreas-kidney) may be considered medically necessary when ALL relevant criteria below are met.

Pancreas Transplant (Initial and Retransplant)

Transplant Scenarios
- Simultaneous pancreas-kidney (SPK) transplant for insulin-dependent diabetic individuals with uremia.
- Pancreas transplant after a prior kidney transplant (PAK) in insulin-dependent diabetic individuals who meet pancreas transplant criteria.
- Pancreas transplant alone (PA) for nonuremic insulin-dependent diabetic individuals with severely disabling and potentially life-threatening complications due to hypoglycemia unawareness or labile diabetes that persists despite optimal medical management.
Pancreas-alone Specific Severity Criteria

Detailed kidney transplant initial criteria:

ALL of the following

Diagnosis of end-stage renal disease (ESRD) with documentation of severity and need for renal replacement therapy or anticipated need.
Comprehensive pre-transplant evaluation documenting cardiopulmonary fitness, infection screening, malignancy screening, and psychosocial assessment consistent with transplant program standards.
Absence of contraindications to transplantation, including uncontrolled infection, active malignancy not in remission per transplant program criteria, or other conditions making the procedure futile.
Selection should follow transplant center protocols and registry-informed practice; documentation should be maintained in the medical record.

Detailed kidney retransplant criteria:

ALL of the following

History of prior kidney transplant with graft failure and current need for renal replacement therapy or anticipated need for retransplantation.
Evaluation demonstrates absence of contraindications to retransplantation (see initial criteria).
Clinical assessment indicates potential benefit from retransplantation based on survival, functional status, and expected post-transplant care.
Registry data support reasonable survival after retransplant in appropriately selected patients; document rationale for retransplant.

Pancreas transplant types and criteria overview:

Pancreas Transplant Types

Pancreas-alone (PA): for nonuremic insulin-dependent diabetic individuals with severe hypoglycemia unawareness or labile diabetes despite optimal medical therapy; requires documentation of severity as described above.
Pancreas after kidney (PAK): for insulin-dependent diabetic individuals who have previously received a kidney transplant and meet pancreas transplant criteria.
Simultaneous pancreas-kidney (SPK): for insulin-dependent diabetic individuals with uremia; candidate must meet both kidney and pancreas transplant selection criteria.

Coverage Statements

Kidney transplants (living or deceased donor) are considered medically necessary for carefully selected candidates with end-stage renal disease.
Kidney retransplantation after a failed primary kidney transplant is considered medically necessary for individuals who meet transplant criteria.
Pancreas transplants (SPK, PAK, PA) are considered medically necessary for appropriately selected insulin-dependent diabetic individuals as specified above.
Pancreas retransplant after a failed primary pancreas transplant may be considered medically necessary in individuals who meet criteria for pancreas transplantation.
Kidney and pancreas transplants are considered investigational for all other situations not meeting the criteria above due to insufficient evidence to support benefit.

Investigational / Not covered statements and operational notes:

ANY of the following

Transplant procedures that do not meet the medical necessity criteria outlined above are considered investigational.
Transplantation is contraindicated when the procedure is expected to be futile because of comorbid disease or when required post-transplant care would significantly worsen comorbid conditions.
No explicit list of 'not medically necessary' procedures is provided here; final coverage depends on the member's benefit program and clinical review.

Provider action / billing considerations:

ALL of the following

Prior authorization and documentation of transplant evaluation, including evidence supporting severity criteria for pancreas-alone and absence of contraindications, are required per plan and transplant center protocols.
Claims are subject to benefit plan terms, eligibility verification, and medical necessity review.

Coding and Diagnosis Thresholds

Covered when medically necessary - Procedure Codesmixed

50323	Procedure Codes
50325	Procedure Codes
50327	Procedure Codes
50328	Procedure Codes
50329	Procedure Codes
50340	Procedure Codes
50360	Procedure Codes
50365	Procedure Codes
50380	Procedure Codes
50547	Procedure Codes

1–10 of 18

1/2

Covered when medically necessary - Diagnosis (ICD-10)ICD-10Covered

E10.10	Type 1 diabetes mellitus with ketoacidosis without coma.
E10.11	Type 1 diabetes mellitus with ketoacidosis with coma.
E10.21	Type 1 diabetes mellitus with diabetic nephropathy.
E10.22	Type 1 diabetes mellitus with diabetic chronic kidney disease.
E10.29	Type 1 diabetes mellitus with other diabetic kidney complication.
E10.641	Type 1 diabetes mellitus with hypoglycemia with coma.
E10.649	Type 1 diabetes mellitus with hypoglycemia without coma.
E10.65	Type 1 diabetes mellitus with hyperglycemia.
E10.69	Type 1 diabetes mellitus with other specified complication.
E10.8	Type 1 diabetes mellitus with unspecified complications.

1–10 of 18

1/2

Coding review notesmixed

No codes listed

Listing consideration threshold

Listing consideration thresholdGFR or measured/estimated creatinine clearance ≤ 20 mL/min OR initiation of regularly‑administered dialysis (used to calculate waiting time)

Listing documentationEarliest date of GFR ≤20 mL/min or dialysis initiation should be documented for waiting‑time calculation

No mandatory listing GFRThere are no absolute medical criteria required to be listed for kidney transplant; these thresholds are for waiting‑time calculation only

ESRD definition threshold

ESRD (chronic kidney disease stage 5) thresholdGlomerular filtration rate (GFR) < 15 mL/min/1.73 m2

Clinical implicationStage 4 (GFR 15–29) and stage 5 patients should be evaluated for transplant; ESRD is lifethreatening and may require dialysis or transplant

Definition summaryESRD: inability of kidneys to perform functions (filter wastes/excess fluids) often requiring hemodialysis or transplantation

Survival examples

Kidney retransplant 5‑year survival exampleReported 5‑year survival range for kidney retransplant: 87%–96%

Pancreas after kidney 3‑year survival exampleExample 3‑year patient survival after pancreas transplant after kidney: 94.5%

Pancreas transplant alone 3‑year survival exampleExample 3‑year patient survival after pancreas transplant alone: 94.9%

Coding notes

Procedure and diagnosis code groupsProcedure and ICD‑10 diagnosis code groups are listed in the coding section; identification of a code does not guarantee coverage

Procedure codes (example)Codes listed in policy include: 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50380, 50547, S2152, 48550–48556, 50300, 50320

Diagnosis codes (example)ICD‑10 examples include: N18.6 (ESRD), Z94.0 (kidney transplant status), E10.x diabetes codes, T86.x transplant complications

Provider Actions, Authorization, and Documentation

Billing Rule

Procedure codes listed (verification required)

Procedure codes are listed for informational purposes only. Inclusion of a code does not guarantee coverage; verify coding and reimbursement against the member's benefit plan and current coding updates prior to billing.

Code list does not imply coverage
Provider should confirm eligibility and benefits on date of service

Prior Authorization

Prior authorization requirement

Prior authorization is required for organ transplant procedures when specified by the member's benefit plan. Providers must obtain administrative authorization or follow the transplant center referral and precertification processes before scheduling transplant services.

Check member eligibility and prior authorization requirements with Capital BlueCross Provider Services
Submit required clinical documentation to support medical necessity

Step Therapy

There are no explicit step therapy requirements in this section of the policy. No sequential or stepwise medical therapy prerequisites are imposed for transplant coverage by this document.

No step therapy applies to transplant listing or selection per this policy text

Denial Risk

No explicit denial triggers are stated

This policy does not enumerate explicit denial triggers beyond standard medical necessity and contraindication guidance; however, providers should note that transplants may be denied if medical necessity criteria are not met or if the procedure is expected to be futile.

Final coverage determination depends on member benefits, eligibility, and documented medical necessity
Known high-risk conditions (e.g., active malignancy, untreated systemic infection, substance use disorder, documented nonadherence) may lead to denial

Candidate Selection and Eligibility Criteria

Candidate Criteria

Candidate selection principles and specific severity criteria for pancreas-alone candidates

Kidney candidate selection: Candidate has end-stage renal disease (ESRD) and is selected by transplant center without contraindications

Waiting time calculations use earliest date of GFR ≤20 mL/min or initiation of regularly-administered dialysis.

Pancreas-alone candidate severity: Candidate must have either severe hypoglycemia unawareness OR potentially life-threatening labile diabetes despite optimal medical management

Documentation via chart notes, emergency department visits, or hospitalization for diabetic ketoacidosis required.

Candidate Criteria

Candidate selection and evidence-based outcomes cited for covered transplants:

Kidney transplant candidate: ESRD patients without contraindications; living or deceased donor grafts considered

Registry data demonstrate survival benefit vs waiting list

Kidney retransplant candidate: Patients with failed kidney transplant who meet selection criteria and have no contraindications

Registry data show favorable retransplant outcomes (e.g., 5‑year survival 87%–96%)

Pancreas/SPK candidate: Insulin-dependent diabetes patients (with or without uremia depending on transplant type) who meet clinical criteria

Registry and retrospective studies support patient and graft survival benefits (examples: pancreas after kidney 3‑year survival 94.5%; pancreas alone 3‑year survival 94.9%)

Contraindications and Futility

Known current malignancy, recent malignancy with a high risk of recurrence, untreated systemic infection that would make immunosuppression unsafe, other irreversible end-stage disease not attributable to the target organ, and psychosocial or chemical dependency issues that impair adherence are examples of conditions that may serve as contraindications to transplantation.

An absolute or relative contraindication exists when the transplant is expected to be futile due to comorbid disease or when provision of necessary post-transplant care is not possible or is expected to substantially worsen comorbid conditions; in such situations transplantation would be contraindicated.

Some cited chunks in the extract do not provide an explicit list of contraindications. Where contraindications are not listed, clinical judgment by the transplant team and established guidelines should guide evaluation.

In portions of the document provided there are no explicit denial triggers stated. Absence of such language in these excerpts means denials would be based on the policy’s stated contraindications, investigational exclusions, and applicable benefit terms.

Pre-Transplant Evaluation and Documentation

Prior Authorization

No specific preapproval steps listed

The extract does not list specific preapproval procedural steps beyond standard transplant candidate selection; no distinct preauthorization checklist is included here.

Documentation Required

Evaluation informed by OPTN/UNOS and national guidelines

Evaluation and selection should be informed by OPTN/UNOS policies and national guidelines and registry data; detailed pre-approval evaluation steps are referenced but not specified in this extract.

Documentation Required

Infectious-disease and standard evaluation guidance referenced

Cited references include infectious disease guidance and registry data (e.g., AST/OPTN guidance, HIV transplant literature), indicating standard evaluation includes infectious disease assessment and related considerations.

Transplant Center and Program Requirements

Note

Transplant center judgment on contraindications

The policy notes that assessment of potential contraindications is subject to the judgment of the transplant center; no explicit accreditation, minimum volume, or center‑specific certification requirements are specified in these chunks.

Note

Blue Distinction Centers referenced (no specifics)

Blue Distinction Centers for Transplant are referenced as a program to provide access to leading centers, but specific accreditation or volume requirements are not detailed in this extract.

Note

CMS/OPTN certification implied; no explicit center rules

References to CMS transplant certification and OPTN policies are cited, implying centers should adhere to applicable certification and regulatory requirements, though explicit center requirements are not provided in these chunks.

Post-Transplant Coverage and Claims

Post‑transplant care and services

Post‑transplant coverage dependencyPost‑transplant care and claim payment depend on the member's benefit program and eligibility on the date of service; policy is not a guarantee of coverage

Documentation expectationSupportive documentation may include registry/guideline references (OPTN/UNOS, CMS) but final coverage is per member contract

Provider responsibilityTreating providers are responsible for medical advice and treatment; questions should be directed to Provider or Member Services

Post‑transplant coverage duration

No explicit duration statedNo specific post‑transplant coverage duration or explicit post‑transplant rules are provided in these policy chunks

Claim adjudication noteFinal claim processing depends on member benefit program, eligibility date, and determination of medical necessity

RecommendationRefer to member contract and payer Provider/Member Services for benefit limits and duration details

Background and Rationale

Solid organ transplantation of the kidney and pancreas can be lifesaving or substantially improve quality of life for patients with end-stage organ failure. Transplant candidates require lifelong immunosuppression and are prioritized and selected according to registry and guideline-informed criteria; benefits demonstrated in registry data include improved survival versus remaining on the waiting list for appropriately selected patients.

Definitions and Terms

End‑stage renal disease (ESRD) definition and thresholds

ESRD definitionEnd‑stage renal disease (ESRD): inability of kidneys to perform functions; chronic kidney disease stage 5 defined as GFR < 15 mL/min/1.73 m2

Evaluation recommendationPatients with advanced CKD (stage 4: GFR 15–29 and stage 5: GFR <15) should be evaluated for transplant; being on dialysis is not required to be considered

Waiting‑time calculationWaiting time uses earliest documented date of GFR ≤20 mL/min or initiation of regularly‑administered dialysis

ABSOLUTE CONTRAINDICATION

ABSOLUTE CONTRAINDICATION definitionAn absolute contraindication is a reason for not performing a therapeutic intervention that is so compelling or risky that its performance would reasonably be regarded as malpractice.

Implication for transplantAbsolute contraindications preclude performing the transplant procedure

Contrast with relative contraindicationA relative contraindication makes a procedure inadvisable but does not absolutely rule it out

END‑STAGE RENAL DISEASE (ESRD)

END‑STAGE RENAL DISEASE (ESRD) definitionESRD: kidney damage or scarring so severe that hemodialysis or transplantation is required for survival

Clinical noteESRD is lifethreatening and synonymous with chronic kidney disease stage 5 (GFR <15 mL/min/1.73 m2)

Transplant indicationKidney transplant is an accepted treatment for ESRD from deceased or living donors

BLUE DISTINCTION CENTERS FOR TRANSPLANT (BDCT)

Blue Distinction Centers for Transplant (BDCT)A cooperative effort of Blue Cross and Blue Shield Plans and participating institutions to provide patients access to leading transplant centers via a coordinated transplant management program

Program purposeFacilitates access to leading transplant centers through streamlined transplant management

Not an accreditation mandate in this extractSpecific accreditation or volume requirements for centers are not detailed in these chunks

simultaneous kidney/pancreas transplant

Simultaneous kidney/pancreas (SPK) definitionSimultaneous kidney/pancreas transplant (SPK): transplant of kidney and pancreas together for insulin‑dependent diabetes with uremia

Outcome noteRegistry data show relatively high patient survival after SPK and improved survival versus waiting list in type 1 diabetes

Related scenariosSPK is considered alongside pancreas after kidney and pancreas alone in evidence reviews and outcome summaries

Policy History and References

2025-08-22Consensus ReviewLatest

Updated policy guidelines, product variations, background, rationale, ICD-10 table, and references; no changes to procedure codes.

2024-07-25Consensus Review

No change to policy statements; references reviewed and updated and coding reviewed with no coding changes.

2024-01-19Administrative Update

Clinical benefit added.

2023-09-12Consensus Review

No change to policy statement; background updated and references reviewed and updated; coding reviewed, no changes.

2022-12-14Consensus Review

No change to policy statement; FEP, background, and references updated; no coding changes.

2021-07-12Consensus Review

No change to policy statement; coding reviewed; background, rationale, and references updated.

2020-08-24Consensus Review

Policy statement unchanged; FEP and product variation statements updated; references reviewed and updated; coding reviewed with no changes.

Policy Summary

PayerCapital Bluecross

PolicyKidney Transplants, Pancreas Transplants, and Simultaneous Kidney/Pancreas Transplants

Policy CodePolicy MP 9.005

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument renal function trajectory (dates of GFR ≤20 mL/min or dialysis initiation) and other evaluation information when requesting transplant listing or coverage.

SourceLink

On This Page

Documentation of severe hypoglycemia unawareness as evidenced by chart notes, emergency department visits, or other objective clinical documentation.

OR documentation of potentially life-threatening labile diabetes as evidenced by chart notes or hospitalization for diabetic ketoacidosis.

General Requirements

Most candidates for pancreas transplant will have type 1 diabetes mellitus, but candidates with type 2 diabetes may be considered per registry and transplant center practice when meeting severity criteria.
Pancreas retransplantation may be considered medically necessary in individuals who meet criteria for pancreas transplantation and who have had a failed primary pancreas transplant.

Coverage determinations remain subject to member benefit plan language, eligibility on the date of service, and medical necessity review by Capital Blue Cross. Providers must provide documentation supporting how the candidate meets the specific criteria for the requested transplant.