CurrentFidelis CarePolicy 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/Fidelis Care, including candidate selection and contraindications.

Policy Summary

PayerFidelis Care

PolicyPediatric Kidney Transplant

Policy CodePolicy MC.CP.MP.246

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating the candidate is pediatric (age <18) with ESRD (GFR <15) or CKD stage 4 (GFR <30) with expected progression and lacks listed contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age < 18patient age for policy applicability

GFR < 15ESRD threshold (stage 5)

GFR < 30CKD stage 4 threshold

KDIGOPrimary guideline sources

Coverage and Medical Necessity Criteria

Initial transplant candidate medical necessity

Covered when ALL of the following are met

Primary eligibility: Member/enrollee is pediatric (age < 18) and has advanced renal disease defined as either ESRD (GFR < 15 mL/min/1.73m2) OR CKD stage 4 (GFR < 30 mL/min/1.73m2) in those expected to reach ESRD.GFR thresholds as stated

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

Absence of contraindications: Candidate does not have any listed contraindications including: active infection that is not properly treated (except hepatitis C managed per guideline); HIV infection with detectable viral load unless all of the following are documented: CD4 > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and currently on effective antiretroviral therapy (ART); active malignancy with high risk of recurrence or death; stroke within the past 6 months or TIA within the past 3 months (cardiology clearance required for prior MI); active symptomatic cardiac disease not evaluated by a cardiologist; active symptomatic peripheral arterial disease not properly managed; inability to adhere to the regimen necessary to preserve the transplant even with caregiver support; active or ongoing substance use disorder that affects decision‑making or increases post‑transplant risk; acute pancreatitis within the past 3 months; decompensated cirrhosis unless candidate for combined liver‑kidney transplant; elevated circulating anti‑GBM antibodies.

Policy Summary

PayerFidelis Care

PolicyPediatric Kidney Transplant

Policy CodePolicy MC.CP.MP.246

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating the candidate is pediatric (age <18) with ESRD (GFR <15) or CKD stage 4 (GFR <30) with expected progression and lacks listed contraindications.

SourceLink

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The policy lists specific contraindications that must be absent or resolved prior to approval. These include active untreated infection (with the hepatitis C exception when managed), uncontrolled HIV (detectable viral load unless documented CD4 > 200, no active AIDS‑defining infection, and on effective ART), active malignancy with high recurrence risk, recent neurologic events (stroke within 6 months or TIA within 3 months), active symptomatic cardiac or peripheral arterial disease not evaluated/managed, inability to adhere to required regimens, active substance use disorder that affects decision‑making, acute pancreatitis within the past 3 months, decompensated cirrhosis (unless combined transplant candidate), and elevated anti‑GBM antibodies.

Contraindications Affecting Coverage

Candidates are contraindicated for transplant if they have any of the following until the condition is appropriately treated or managed: active infection that is not properly treated; HIV with detectable viral load unless all of these are documented—CD4 > 200 cells/mm3, absence of active AIDS‑defining infection, and current effective antiretroviral therapy; 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 disease not evaluated by cardiology (cardiology clearance required after MI); active symptomatic peripheral arterial disease not properly managed; inability to adhere to transplant regimen despite caregiver support; active or ongoing substance use disorder that impairs decision‑making or increases post‑transplant risk; acute pancreatitis within 3 months; decompensated cirrhosis unless candidate for combined liver–kidney transplant; and elevated circulating anti‑GBM antibodies.

Pre-Transplant Evaluation Requirements

Denial Risk

Contraindications That May Lead to Denial

Contraindications that may lead to denial include any of the following unless specifically addressed and documented: active infection not adequately treated (except HCV per KDIGO guidance); HIV with detectable viral load (unless CD4 >200 cells/mm3, no active AIDS‑defining opportunistic infection, and patient on effective antiretroviral therapy); active malignancy with high risk of recurrence or death; recent cerebrovascular events (stroke within 6 months or TIA within 3 months); active symptomatic cardiac disease not evaluated/cleared by cardiology (including recent MI requiring cardiology clearance); active symptomatic peripheral arterial disease not properly managed; inability to adhere to required post‑transplant regimen despite caregiver support; active/ongoing substance use disorder that impairs decision‑making or increases post‑transplant risk; acute pancreatitis within prior 3 months; decompensated cirrhosis unless candidate for combined liver‑kidney transplant; and elevated circulating anti‑glomerular basement membrane antibodies.

Active infection not adequately treated (except HCV when managed per KDIGO)
HIV with detectable viral load — allowed only if: CD4 >200 cells/mm3; no active AIDS‑defining opportunistic infection; on effective ART
Active malignancy with high recurrence/death risk
Stroke within 6 months or TIA within 3 months (cardiology clearance required for recent MI)
Active symptomatic cardiac disease not evaluated by cardiology
Active 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 or increasing post‑transplant risk
Acute pancreatitis within past 3 months
Decompensated cirrhosis unless candidate for combined liver‑kidney transplant
Elevated circulating anti‑GBM antibodies

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Obtain prior authorization showing pediatric medical necessity

Prior authorization is required and must demonstrate medical necessity: the candidate is pediatric (age < 18) and has either ESRD (GFR < 15 mL/min/1.73m2) or CKD stage 4 (GFR < 30 mL/min/1.73m2) with expected progression to ESRD, and does not have any listed contraindications.

Age < 18.
ESRD: GFR < 15 mL/min/1.73m2 OR CKD stage 4: GFR < 30 mL/min/1.73m2 with expected progression to ESRD.
Absence of listed contraindications per policy.

Documentation Required

Submit required clinical documentation (GFR, etiology, contraindication management)

Include objective clinical documentation showing GFR values that meet criteria and records addressing causes and management of contraindications.

Document GFR demonstrating ESRD (GFR < 15) or CKD stage 4 (GFR < 30) with expected progression to ESRD.
Provide records that determine or describe the cause of ESRD when possible.
Supply documentation of management or absence of contraindications (e.g., infection treatment, oncology status, cardiology clearance, HIV control and ART).

Denial Risk

Contraindications may trigger denial if present/unmanaged

Presence of any listed contraindication may result in denial until resolved or appropriately managed; examples include active untreated infection, uncontrolled HIV without documented control, active malignancy with high recurrence risk, recent stroke/TIA, active symptomatic cardiac disease not evaluated, and others as listed.

Active infection not properly treated (except managed hepatitis C).
HIV with detectable viral load unless CD4 > 200, 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; cardiology clearance required after MI.
Active symptomatic cardiac or peripheral arterial disease not evaluated/managed; inability to adhere; active substance use disorder; acute pancreatitis within 3 months; decompensated cirrhosis unless combined transplant; elevated anti‑GBM antibodies.

Step Therapy

Step therapy not specified; preemptive living-donor transplant preferred

Step therapy or sequencing requirements are not specified in this policy; the guidance notes that preemptive transplantation from a living donor is preferred when appropriate.

No required sequencing of therapies is specified in the policy.
Preemptive (primary) transplant, often from a living related donor, is the preferred option when feasible.

Procedure and Billing Codes

Referenced CPT codes (donor and transplant procedures)CPT

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/Special codesHCPCS

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

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

CKD stage 4GFR < 30 mL/min/1.73m2 (in members expected to progress to ESRD)

Policy age applicabilityPediatric members/enrollees (age < 18) when thresholds met

OpenPayer

Clinical Policy: Pediatric Kidney Transplant

Coverage and Medical Necessity Criteria

Contraindications Affecting Coverage

Pre-Transplant Evaluation Requirements

Provider Requirements, Prior Authorization, and Documentation

Procedure and Billing Codes

Key Definitions

Background and Clinical Context

Transplant Center and Operational Requirements

Post-Transplant Care and Related Services