CurrentCentenePolicy CP.MP.102

Clinical Policy: Pancreas Transplantation

Customize your policy alerts

Sign up for Centene Policy CP.MP.102 alerts

Get alerted when Policy CP.MP.102 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical policy governing medical necessity and coverage criteria for pancreas transplantation for Centene members; affects providers submitting requests for pancreas transplant services and associated CPT coding.

Policy Summary

PayerCentene

PolicyClinical Policy: Pancreas Transplantation

Policy CodePolicy CP.MP.102

Change TypeCriteria revisionscoding addition

Effective Date

Next Review Date

Key ActionObtain prior authorization and include CPT 50328 when submitting requests for pancreas transplant procedures.

SourceLink

POLICY UPDATE CHANGES

Changed time frame for myocardial infarction language from 'within 30 days' to 'within 6 months' and reworded stroke/acute coronary syndrome information.

Added I.C.1.a.ii 'Recurring severe hypoglycemic attacks'.

Added CPT code 50328.

50328new code referenced in update notes

6 monthsMI timeframe updated

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCentenePolicy CP.MP.102

Clinical Policy: Pancreas Transplantation

Customize your policy alerts

Sign up for Centene Policy CP.MP.102 alerts

Get alerted when Policy CP.MP.102 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCentene

PolicyClinical Policy: Pancreas Transplantation

Policy CodePolicy CP.MP.102

Change TypeCriteria revisionscoding addition

Effective Date

Next Review Date

Key ActionObtain prior authorization and include CPT 50328 when submitting requests for pancreas transplant procedures.

SourceLink

POLICY UPDATE CHANGES

Changed time frame for myocardial infarction language from 'within 30 days' to 'within 6 months' and reworded stroke/acute coronary syndrome information.

Added I.C.1.a.ii 'Recurring severe hypoglycemic attacks'.

Added CPT code 50328.

50328new code referenced in update notes

6 monthsMI timeframe updated

Coverage Criteria and Policy Revisions

Revised criteria summary

Policy criteria sections I.A, I.B and I.C were revised as noted; specifics available in full policy.

I.A.1 specification: Specified 'type I' diabetes in I.A.1

clarification added

I.B.2.c dialysis dependence: I.B.2.c modified to add 'or dialysis dependent'

clarifies renal failure status

I.B.3.c.ii medication threshold: Added specification 'greater than 500 mg/day'>500 mg/day

numeric threshold for medication dosage

I.C.1.a.ii recurrent hypoglycemia: Added 'Recurring severe hypoglycemic attacks' (moved contraindications from I.B to I.C)

new explicit criterion/contraindication

Per the recent revision notes, the policy relocated the list of contraindications from section I.B to section I.C. The source chunks do not enumerate specific contraindications in the extract provided; the update entry documents only that contraindications were moved and that references/background were updated.

The provided chunks do not include explicit statements for this coverage sub-section. The revision summary indicates wording edits across criteria sections (I.A, I.B, I.C) but does not add additional content for this specific item in the excerpt supplied.

Coding and Billing Codes

Covered CPT Codes (addition)CPTCovered

50328

CPT code added to pancreas transplant coding list

Medication threshold

Medication threshold (I.B.3.c.ii)> 500 mg/day

ContextNumeric dosage threshold was added to pretransplant medication criteria in section I.B.3.c.ii

Location in policySection I.B.3.c.ii

Provider Actions, Authorization & Alerts

Prior Authorization

Prior Authorization Required

Prior authorization is required for pancreas transplant procedures. Include CPT code 50328 when requesting prior authorization for pancreas transplant.

CPT 50328

Note

Provider Impact

Provider-impact placeholder: no additional summary available from source chunks. Check clinical criteria revisions for potential effects on pretransplant documentation and authorization decisions.

Documentation Required

Documented Clinical Criteria Revisions

Clinical criteria revisions documented: specification of “type I” diabetes in initial criteria (I.A.1); modifications to pretransplant requirements including changes to cardiac event timing language and addition of recurring severe hypoglycemic attacks; movement of contraindications from section I.B to I.C; specification that certain medication thresholds are > 500 mg/day; and addition of dialysis-dependent language. These revisions may affect eligibility determinations and required documentation for authorization.

Definitions and Terminology

Recurring severe hypoglycemic attacks

New explicit criterionRecurring severe hypoglycemic attacks added as I.C.1.a.ii

RoleListed under contraindications/criteria section I.C (moved from I.B)

ImplicationSpecifies recurrent severe hypoglycemia as an explicit consideration for candidate selection

Candidate Selection Criteria

Candidate criteria edits

Policy edits reference candidate selection language (full candidate criteria are in the main policy text).

Type I diabetes specification: I.A.1 now specifies 'type I' diabetes

clarifies eligible diabetes type for pancreas transplant candidacy

Recurring severe hypoglycemia: I.C.1.a.ii added 'Recurring severe hypoglycemic attacks' as an explicit candidate/indication or contraindication criterion

newly added clinical criterion

Contraindications

Contraindications were moved from section I.B to I.C during the update. The excerpted text documents the relocation but does not list individual contraindications; reviewers should consult the full policy text for the specific contraindication entries now housed under I.C.

Evaluation and Pre-Transplant Requirements

Documentation Required

Evaluation requirements — confirm full policy text

Pretransplant evaluation language in I.B was reworded and references/background were updated; specific stepwise evaluation requirements are not present in the provided chunks, so ensure records submitted reflect current I.B language from the full policy.

I.B sections reworded (e.g., I.B.1.a/b), but full evaluation steps must be confirmed against the complete policy text

Center and Program Requirements

Note

Center requirements — verify against full policy

Policy wording for center-level language was updated (I.B.1.a: 'room' replaced with 'department'); the provided chunks do not list accreditation or explicit center requirements — verify center accreditation and department-level requirements against the full policy.

I.B.1.a wording changed: 'room' → 'department'
No explicit accreditation requirements present in these chunks

Post-Transplant Coverage

Post-transplant coverage note

Post-transplant coverage detailsNo post-transplant coverage details present in these document chunks

Update typeAdministrative updates and coding additions (CPT 50328) only

Where to find more infoRefer to full policy text for any post-transplant service rules or durations not included here

Background and References

Background material for the pancreas transplantation policy was revised in the recent review. The revision notes state that references were reviewed and updated and that clinical sources (background and references) were updated to align with current guidance. The document framing references clinical guidance for pancreas/islet transplantation and type 1 diabetes and indicates the criteria edits (for example, specifying type I diabetes and adding recurring severe hypoglycemic attacks as an explicit criterion). Providers should refer to UpToDate and ADA guidance cited in the full policy reference list for clinical context and rationale.