CurrentCentenePolicy CP.MP.246

Pediatric Kidney Transplant

Medical necessity criteria and coverage guidance for kidney transplantation in pediatric members/enrollees (age <18) for non‑Medicare Centene health plans.

Policy Summary

PayerCentene

PolicyPediatric Kidney Transplant

Policy CodePolicy CP.MP.246

Change TypeCriteria revision (GFR thresholds) and contraindication clarifications

Effective Date

Next Review Date

Key ActionObtain prior authorization for pediatric kidney transplantation and associated donor procurement/transplant services using referenced CPT/HCPCS codes.

SourceLink

POLICY UPDATE CHANGES

Updated GFR threshold for ESRD indication from <15 mL/min/1.73m2 to ≤15 mL/min/1.73m2 and added CKD stage 4 (GFR <30 mL/min/1.73m2) expected to progress to ESRD as an indication.

Contraindications list updated to align with KDIGO guidelines, including clarification for HIV criteria (viral load/CD4), active infections, malignancy, cardiac disease, recent stroke/MI, substance use disorder, inability to adhere, and active liver disease.

Note directing readers to separate Medicare-specific criteria (MC.CP.MP.246).

age < 18pediatric population covered

GFR ≤ 15ESRD indication threshold

GFR < 30CKD stage 4 threshold

multiple listedcontraindications

10 codesprocedure codes

Coverage Criteria for Pediatric Kidney Transplantation

Initial transplant candidacy

Covered when ALL of the following are met for non‑Medicare pediatric members/enrollees (age <18):

Primary indications: 1) End-stage renal disease (ESRD) (stage 5) with glomerular filtration rate (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/enrollees who are expected to reach ESRD; preemptive transplantation from a living donor may be considered when appropriate.GFR ≤ 15 mL/min/1.73 m2; CKD stage 4 GFR < 30 mL/min/1.73 m2 when expected to progress to ESRD

Sourced to KDIGO and OPTN guidance as reflected in policy update

Contraindications absent: Candidate must NOT have any contraindications listed in the policy (see Contraindications / Exclusion criteria block).N/A

Contraindications aligned with KDIGO guidance

Policy Summary

PayerCentene

PolicyPediatric Kidney Transplant

Policy CodePolicy CP.MP.246

Change TypeCriteria revision (GFR thresholds) and contraindication clarifications

Effective Date

Next Review Date

Key ActionObtain prior authorization for pediatric kidney transplantation and associated donor procurement/transplant services using referenced CPT/HCPCS codes.

SourceLink

On This Page

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Infections/HIV: Active infection that is not properly treated (except treated hepatitis C per guidance); HIV with detectable viral load unless all of the following documented: on effective antiretroviral therapy (ART), CD4 cell count ≥ 200 cells/mm3, and absence of active AIDS-defining opportunistic infection.CD4 ≥ 200 cells/mm3

HIV criteria expanded (a–c) in policy update

Malignancy: Active malignancy with high risk of recurrence or death related to the malignancy.N/A

Cardiovascular/Cerebrovascular: Active symptomatic cardiac disease (e.g., angina, arrhythmia, heart failure, valvular disease) that has not been evaluated/cleared by cardiology; stroke within the past 6 months or transient ischemic attack within the past 3 months; recent myocardial infarction requires cardiology clearance prior to kidney transplant.stroke within 6 months; TIA within 3 months

Timing and clearance requirements specified in policy

Vascular/Liver/Pancreas: Active symptomatic peripheral arterial disease not properly managed; decompensated cirrhosis unless candidate for combined liver-kidney transplant; acute pancreatitis within the last 3 months.acute pancreatitis within 3 months

Behavioral/Adherence: Active or ongoing substance use disorder that affects decision-making or places the candidate at high post-transplant risk; inability to adhere to the regimen necessary to preserve the transplant even with caregiver support.N/A

Immunologic: Elevated levels of circulating anti-glomerular basement membrane (anti-GBM) antibodies.N/A

Transplantation is considered not medically necessary and should be operationally denied when the candidate has any unresolved contraindication listed in this policy (for example: active untreated infection, uncontrolled HIV per policy criteria, active high‑risk malignancy, active symptomatic cardiac disease without cardiology clearance, recent stroke/MI within specified timeframes without clearance, active substance use disorder that affects decision-making, inability to adhere to the required post‑transplant regimen, decompensated cirrhosis unless a combined liver‑kidney candidate, acute pancreatitis within 3 months, elevated circulating anti‑GBM antibodies, or unmanaged peripheral arterial disease). Requests must document resolution or specialist clearance for any previously identified contraindication before approval is considered.

Procedure and Coding References

Referenced procedure and procurement codesCPT | HCPCS

50300	Donor nephrectomy (including cold preservation); from cadaver donor; unilateral or bilateral.
50320	Donor nephrectomy (including cold preservation); open, from living donor.
50325	Backbench standard preparation of living donor renal allograft (open or laparoscopic) 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 prior.
50327	Backbench reconstruction of cadaver or living donor renal allograft to transplantation; venous anastomosis, each.
50328	Backbench reconstruction of cadaver or living donor renal allograft to transplantation; arterial anastomosis, each.
50329	Backbench reconstruction of cadaver or living donor renal allograft 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.
S2152	Solid organ(s), procurement; transplantation, and related complications; including drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services.

GFR thresholds for transplantation candidacy

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

CKD stage 4 threshold (transplant evaluation)GFR < 30 mL/min/1.73m2 when patient is expected to reach ESRD

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

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for all pediatric kidney transplantation procedures and associated donor procurement/transplant services. Submit a prior authorization request before scheduling transplant or donor nephrectomy procedures to obtain coverage determination.

Applies to recipients < 18 years of age.
Include planned procedure codes (e.g., 50300, 50320, 50360, 50365, 50547) and procurement codes (e.g., S2152) on the request.

Note

Preemptive Transplant Preference

Preemptive (primary) transplantation from a living donor is the preferred treatment for eligible pediatric patients with advanced CKD/ESRD. When clinically appropriate, transplant programs and referring providers should prioritize evaluation for living donor transplantation and document consideration of preemptive transplant in the medical record.

Preemptive transplant is typically considered when the patient is approaching ESRD or has progressive decline in GFR and a suitable living donor is available.
Document discussion of risks/benefits and reasons if dialysis is initiated prior to transplant.

Documentation Required

Required Supporting Documentation

Requests for transplant authorization must include supporting documentation to demonstrate medical necessity and candidate suitability. Incomplete documentation may delay review or result in denial.

Recent measured or estimated GFR values and trend (including dates and method).
Clinical records supporting ESRD or CKD stage 4 with anticipated progression to ESRD.
Multidisciplinary transplant evaluation notes (nephrology, transplant surgery, cardiology, infectious disease, psychiatry/substance use as applicable).
Infectious disease testing and treatment status (HIV viral load, hepatitis B/C status; documentation of effective ART and CD4 count if applicable).
Oncology clearance or documentation of cancer-free interval for prior malignancy when required.
Cardiology evaluation/clearance for active symptomatic cardiac disease or recent MI, stroke, or TIA per policy.
Evidence of ability to adhere to post-transplant regimen and caregiver support assessment.
Planned donor evaluation and procurement documentation for living donors, or intent to use deceased donor and listing status.

Denial Risk

Contraindications That May Trigger Denial

Transplant requests may be denied when contraindications are present that increase the risk of poor outcomes or jeopardize graft survival. Ensure contraindications are addressed, resolved, or clearly documented prior to submission.

Active infection that is not adequately treated (except treated hepatitis C as specified).
HIV infection with detectable viral load or without documented effective ART and acceptable CD4 count and absence of active opportunistic infection.
Active malignancy with high risk of recurrence or death related to the malignancy (unless cleared by oncology for transplant candidacy).
Active symptomatic cardiac disease not evaluated/cleared by a cardiologist (eg, unstable angina, uncontrolled arrhythmia, decompensated heart failure).
Recent stroke (within 6 months) or TIA (within 3 months) without appropriate specialist clearance.
Active symptomatic peripheral arterial disease not adequately managed.
Active or ongoing substance use disorder that impairs decision-making or increases post-transplant risk.
Inability to adhere to required post-transplant regimen despite caregiver support interventions.
Acute pancreatitis within the last 3 months.
Decompensated cirrhosis unless candidate for combined liver-kidney transplant.

OpenPayer

Pediatric Kidney Transplant

Coverage Criteria for Pediatric Kidney Transplantation

Procedure and Coding References

Provider Requirements and Prior Authorization

Background

Definitions and Staging