CurrentKaiser PermanentePolicy N/A

Kaiser Foundation Health Plan of Washington Clinical Review Criteria for Pancreas Transplant Alone and Pancreas After Kidney transplantation

Clinical review criteria from Kaiser Foundation Health Plan of Washington describing principles, indications, contraindications, and documentation requirements for Pancreas Transplant Alone (PTA) and Pancreas After Kidney transplantation; intended for internal use to guide referral and transplant evaluation decisions rather than guarantee coverage.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria for Pancreas Transplant Alone and Pancreas After Kidney transplantation

Policy CodePolicy N/A

Change TypeAdministrative/clarification

Effective DateDec 3, 2024

Next Review Date

Key ActionSubmit a final summary report from the multidisciplinary transplant team to support medical necessity when requesting pancreas transplant services.

SourceLink

POLICY UPDATE CHANGES

MPC approval dates and administrative revision history updated through 12/03/2024.

5Applicable CPT codes listed

pancreas transplantPrimary covered procedure type

2Key absolute contraindication categories

Policy scope and purpose

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This document provides clinical review criteria for Pancreas Transplant Alone (PTA) and Pancreas After Kidney transplantation in the setting of type 1 diabetes. It summarizes principles, indications, contraindications, and documentation requirements to guide referral and transplant evaluation decisions rather than to guarantee coverage.

Intended audience: internal clinical review and referral teams (Kaiser Foundation Health Plan of Washington clinicians and transplant program reviewers) making decisions about referral and evaluation for pancreas transplantation.

Effective date: 2024-12-03. Last substantive content review: 2022-01-10.

Key thresholds and metadata

PayerKaiser Permanente

Policy TitlePancreas Transplant Alone and Pancreas After Kidney Transplantation criteria

Effective Date2024-12-03

Last substantive revision2022-01-10

StatusCURRENT

Age threshold for PTA18-55 (except under special clinical circumstances)

Kidney function threshold for PTAGFR or 24-hour creatinine clearance > 50 ml/minute (if 50-70 ml/minute, assessment of calcineurin inhibitor effect may be required)

Required documentation and authorization actions

Documentation Required

Multidisciplinary transplant team report required

Submit a final summary report from the multidisciplinary transplant team to support medical necessity when requesting pancreas transplant services. Emphasize submission to support medical necessity.

Documentation Required

Kidney function assessment

Provide evidence of native or transplanted kidney function using an accepted formula for GFR or a 24-hour urine creatinine clearance. Emphasize that kidney function must be adequate for PTA and that additional assessment of the potential effect of calcineurin inhibitors may be required when creatinine clearance or GFR is in the 50–70 ml/minute range.

Threshold: GFR or 24-hour creatinine clearance > 50 ml/minute is required for PTA.
If creatinine clearance/GFR is between 50 and 70 ml/minute, assess potential calcineurin inhibitor effect (additional evaluation may be required).

Prior Authorization

Verify authorization requirements

Verify authorization requirements for the specific CPT codes and plan type using the Pre-authorization Code Check before requesting services.

Affected CPT codes: 48550, 48551, 48552, 48554, 48556
Use the Pre-authorization Code Check to confirm authorization requirements by plan type.

Applicable procedure codes

Applicable CPT codes considered medically necessary when criteria are metCPT

48550	Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation.
48551	Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation.
48552	Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each.
48554	Transplantation of pancreatic allograft.
48556	Removal of transplanted pancreatic allograft.

Evidence summary and citations

Evidence summary: The Medical Technology Assessment Committee (MTAC) concluded on 12/12/2001 that there was insufficient high-quality evidence to draw conclusions about the effect of Pancreas Transplant Alone (PTA) on health outcomes; available literature consisted primarily of case series and review data.

Notable historical experience cited: Sutherland et al., Ann Surg 2001 (lessons from >1,000 pancreas transplants) is referenced as background experience rather than as high-quality evidence specific to PTA. Overall evidence specific to PTA is limited and often derived from case series and reviews.

Clinical and historical context

Background and clinical context: Pancreas transplantation is used in patients with type 1 diabetes; after a successful transplant many patients no longer require insulin. Due to the risk of organ rejection, recipients require lifelong immunosuppressive drugs.

Most pancreas transplants are performed in conjunction with kidney transplantation (simultaneous or sequential) because the pancreas elicits a strong immune response and higher doses of immunosuppression that can jeopardize kidney function.

Historically, the first clinical pancreas transplant was performed in 1966; outcomes improved in the 1980s with advances in surgical technique and cyclosporine, and graft survival improved further after introduction of tacrolimus and mycophenolate mofetil in the mid-1990s.

Evidence specifically supporting PTA is limited; MTAC found a lack of quality scientific data and noted that much of the literature consists of case series and reviews rather than empirical studies reporting separate PTA outcomes.

Definitions

PTAPancreas Transplant Alone

COECenter of Excellence (KP approved transplant center)

Document changes and review dates

2001-12-12evidence_review

MTAC review concluded insufficient high-quality evidence to draw conclusions about effect of pancreas transplant alone on health outcomes (case series and review data).

2010-10-05administrative_review

Clinical criteria reviewed (MDCRPC).

2011-08-02administrative_review

Clinical criteria reviewed (MDCRPC).

2012-06-05administrative_review

Clinical criteria reviewed (MDCRPC).

2013-04-02administrative_review

Clinical criteria reviewed (MDCRPC).

2014-02-04administrative_review