CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.246

Clinical Policy: Pediatric Kidney Transplant

Medical necessity criteria and coverage guidance for pediatric (age <18) kidney transplantation for Medicare health plans affiliated with Centene Corporation, including candidate selection and contraindications.

Policy Summary

PayerCommunity Health Plan Washington

PolicyClinical Policy: Pediatric Kidney Transplant

Policy CodePolicy MC.CP.MP.246

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating the patient is pediatric (<18) with ESRD (GFR <15) or CKD stage 4 (GFR <30) expected to reach ESRD and document absence of contraindications or that they have been addressed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age < 18patient population covered

GFR < 15ESRD definition for coverage (stage 5)

GFR < 30CKD stage 4 criterion

multiplecontraindications

Coverage Criteria for Pediatric Kidney Transplant

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Initial transplant eligibility (pediatric Medicare members)

Covered when ALL of the following are met:

Primary eligibility: Patient is pediatric (age < 18) AND has advanced renal disease defined as either (1) ESRD (stage 5) with GFR < 15 mL/min/1.73 m2 OR (2) CKD stage 4 with GFR < 30 mL/min/1.73 m2 in members expected to reach ESRD.ESRD: GFR < 15 mL/min/1.73 m2; CKD stage 4: GFR < 30 mL/min/1.73 m2 when expected to reach ESRD

Patients with GFR > 30 who are rapidly progressing toward ESRD should be referred for transplant evaluation.

Contraindications absent: No contraindications present from the listed set (active untreated infection except HCV; uncontrolled HIV unless criteria a-c met; active malignancy with high recurrence risk; recent stroke/TIA within specified timeframes; active symptomatic cardiac disease without cardiology evaluation or MI without cardiology clearance; active symptomatic peripheral arterial disease not managed; inability to adhere to regimen even with caregiver support; active substance use disorder affecting decision-making; decompensated cirrhosis unless candidate for combined liver-kidney; elevated anti-GBM antibodies).see individual items for timeframes and laboratory/clinical criteria

HIV acceptable only if CD4 > 200 cells/mm3, no active AIDS-defining opportunistic infection, and member is on effective antiretroviral therapy (ART).

State Medicaid coverage provisions may supersede this clinical policy where conflicts exist; when that occurs, state Medicaid rules take precedence. For Medicare members, review applicable Medicare NCDs, LCDs, and Coverage Articles to ensure consistency with Medicare coverage determinations before applying this policy.

Transplant is not medically necessary when any contraindication listed in the policy is present. Key exclusionary conditions include active untreated infection (except HCV), uncontrolled HIV unless documented criteria are met, active malignancy with high recurrence risk, recent cerebrovascular events within specified timeframes, active symptomatic cardiac or peripheral arterial disease that has not been evaluated/managed, inability to adhere to required regimens, active substance use disorder affecting decision-making, decompensated cirrhosis unless candidate for combined liver-kidney transplant, and elevated anti-GBM antibodies.

Pediatric Kidney Transplant Candidate Criteria

Pediatric kidney transplant candidate criteria

Candidate must meet disease severity and not have listed contraindications.

Age and disease severity: Age < 18 AND advanced renal disease defined as either ESRD (stage 5) with GFR < 15 mL/min/1.73 m2 OR CKD stage 4 with GFR < 30 mL/min/1.73 m2 in members expected to reach ESRD.GFR values as specified

Refer rapidly progressing patients with GFR > 30 for evaluation.

Contraindications: Absence of any contraindications enumerated in policy: active untreated infection (except HCV); HIV with detectable viral load unless CD4 > 200 cells/mm3, no active AIDS-defining infection, and on effective ART; active malignancy with high risk of recurrence or death; stroke within past 6 months or TIA within past 3 months; active symptomatic cardiac disease not evaluated by a cardiologist (cardiology clearance required after MI); active symptomatic peripheral arterial disease not properly managed; inability to adhere to required regimen despite caregiver support; active/ongoing substance use disorder affecting decision-making or posing high post-transplant risk; decompensated cirrhosis unless candidate for combined liver-kidney transplant; elevated circulating anti-glomerular basement membrane (anti-GBM) antibodies.

Specific timeframes and clinical/lab criteria are detailed in policy.

Contraindications That Preclude Transplant

Contraindications that preclude transplantation include: active infection not properly treated (except HCV); HIV with detectable viral load unless the member has CD4 > 200 cells/mm3, no active AIDS-defining opportunistic infection, and is on effective ART; active malignancy with high risk of recurrence or death; stroke within the past 6 months or TIA within the past 3 months; active symptomatic cardiac diseaseactive symptomatic peripheral arterial disease not properly managed; inability to adhere to post-transplant regimen despite caregiver support; active/ongoing substance use disorder affecting decision-making; decompensated cirrhosis unless considered for combined liver-kidney transplant; and elevated circulating anti-glomerular basement membrane antibodies.

Billing and Coding

Referenced CPT codesCPT

50300	Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral.
50320	Donor nephrectomy (including cold preservation); open, from living donor.
50323	Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary.
50325	Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior 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.
50327	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each.
50328	Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each.
50329	Backbench reconstruction of cadaver or living donor renal allograft prior 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.

Referenced HCPCS codeHCPCS

S2152

Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition.

GFR thresholds for transplant eligibility — ESRD and CKD stage 4

ESRD (stage 5)GFR < 15 mL/min/1.73 m2

CKD stage 4 (when expected to reach ESRD)GFR < 30 mL/min/1.73 m2

Use in eligibility logicEither ESRD (GFR <15) OR CKD stage 4 (GFR <30) expected to progress to ESRD is required for pediatric transplant consideration

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for pediatric kidney transplant. The request must demonstrate the patient is pediatric (age < 18) with advanced renal disease: either end-stage renal disease (ESRD) with GFR < 15 mL/min/1.73 m2 or chronic kidney disease (CKD) stage 4 with GFR < 30 mL/min/1.73 m2 and expected to progress to ESRD. Rapidly progressing patients with GFR > 30 who are expected to reach ESRD should be referred for transplant evaluation.

Member age < 18
ESRD (stage 5) with GFR < 15 mL/min/1.73 m2
CKD stage 4 with GFR < 30 mL/min/1.73 m2 and expected to reach ESRD

Step Therapy

Step therapy / Sequencing

Step therapy / sequencing: Not applicable. Clinical preference for preemptive (primary) transplant is noted — preemptive transplant (transplant prior to dialysis) is preferred when appropriate and typically involves living donor transplantation.

Preemptive transplantation preferred when appropriate
No required trial of dialysis prior to transplant when candidate meets criteria

Denial Risk

Denial Triggers — Contraindications

Denial may be triggered by presence of contraindications. Prior authorization should include documentation that none of the listed contraindications are present or that contraindications have been appropriately managed/cleared.

Active untreated infection (excluding treated HCV)
Uncontrolled HIV (detectable viral load) without documented CD4 > 200 cells/mm3, absence of active AIDS-defining infection, and on effective ART
Active malignancy with high risk of recurrence or death
Recent stroke (within 6 months) or TIA (within 3 months)
Active symptomatic cardiac disease not evaluated/cleared by cardiology, recent MI without cardiology clearance
Active symptomatic peripheral arterial disease not managed
Inability to adhere to post-transplant regimen despite caregiver support
Active/ongoing substance use disorder affecting decision-making or increasing post-transplant risk
Decompensated cirrhosis unless candidate for combined liver-kidney transplant
Elevated circulating anti-glomerular basement membrane antibodies

Pre-Transplant Evaluation Requirements

Note

Multidisciplinary evaluation per KDIGO — cause of ESRD and specialty clearances

Conduct a multidisciplinary evaluation consistent with KDIGO guidance, including determination of the cause of ESRD when possible and specialty assessments (for example, cardiology clearance after myocardial infarction and evaluation/management of infections and comorbidities) prior to listing.

Determine etiology of ESRD when possible per KDIGO recommendations.
Obtain cardiology evaluation/clearance for cardiac disease or after MI.
Evaluate and manage infections and other comorbid conditions before transplant listing.

Key Definitions

ESRD (stage 5) definition

DefinitionEnd-stage renal disease (ESRD, stage 5) defined as GFR < 15 mL/min/1.73 m2

ContextESRD is one of the qualifying advanced renal disease states for pediatric kidney transplant candidacy

Clinical noteDetermination of transplant candidacy requires multidisciplinary evaluation per KDIGO guidance

CKD stage 4 (pediatric) — threshold and expectation

CKD stage 4 thresholdGFR < 30 mL/min/1.73 m2

ApplicabilityApplies when the pediatric member is expected to reach ESRD (i.e., progression to stage 5)

Referral notePatients with GFR >30 who are rapidly progressing toward ESRD should be referred for transplant evaluation

Post-Transplant and Related Services

Comprehensive transplant care — HCPCS S2152

HCPCS S2152 descriptionSolid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition

ScopeCovers procurement, transplantation, complications, and related pre- and post-transplant services

Billing implicationUsed as a comprehensive/bundled HCPCS entry for solid organ transplant episodes of care