CurrentKaiser PermanentePolicy N/A

Pancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) — Coverage Criteria

Guidelines for referral, evaluation, contraindications, and coding for Pancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyPancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRefer patients only after at least 12 months of intensive endocrinology management and submit the multidisciplinary transplant team summary to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18–55Typical eligible age range

GFR>50Minimum kidney function

BMI≥35Relative contraindication

6 moSubstance-abuse abstinence

Coverage Criteria — Pancreas Transplant (PTA / PAK)

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PTA/PAK Medical Necessity Criteria

Covered when ALL of the following are met for Pancreas Transplant Alone (PTA) or Pancreas After Kidney (PAK):

PTA/PAK baseline criteria: 1) Type 1 diabetes with disabling and potentially life‑threatening complications such as brittle diabetes with severe recurrent hypoglycemia (seizures, loss of consciousness, emergency calls), recurrent diabetic ketoacidosis (DKA), or hypoglycemic unawareness requiring constant supervision; 2) Optimally and intensively managed by an endocrinologist for at least 12 months; 3) Age 18–55 unless special clinical circumstances justify exception; 4) Native or transplanted kidney functioning with GFR (by an accepted formula) or 24‑hour creatinine clearance >50 ml/min.

Apply with clinical judgment; these are referral guidelines, not automatic inclusion/exclusion.

Transplant Candidate Selection Criteria

Transplant candidate criteria

Candidate selection criteria and general principles:

General candidate prerequisites: a) Early referral when clinical parameters indicate end‑stage or life‑threatening disease; b) No uncontrolled active infection; c) Abstinent from alcohol and other substance abuse for 6 months with documented evaluation and low risk of recidivism; d) Adequate social support and proven adherence to medical treatment; e) Ability to travel on short notice to the KP approved Center of Excellence and availability of caregiver(s) able to travel and assist; f) No significant irreversible neurologic dysfunction or active psychiatric/behavioral conditions that prevent adherence.

Exceptions may be considered case‑by‑case.

Specific contraindications: Significant irreversible coronary artery disease and/or left ventricular dysfunction; irreversible pulmonary disease; irreversible peripheral vascular disease (note: prior amputation alone is not an absolute contraindication); uncontrolled hypertension.

These conditions are listed as contraindications for PTA/PAK.

Relative considerations: BMI ≥ 35 (may be referred to the Center of Excellence for individual consideration; concurrent referral for weight‑loss intervention is an option); cachexia or malnourishment.BMI ≥ 35

Manage per COE evaluation and consider weight‑loss interventions when appropriate.

Medical Contraindications

Absolute contraindications — Patients with any of the following should not be referred for transplant: significant irreversible coronary artery disease and/or left ventricular dysfunction; irreversible pulmonary disease; irreversible peripheral vascular disease (including carotid vascular disease; note: prior amputation alone is not a contraindication); uncontrolled active infection; uncontrolled hypertension; presence of significant irreversible neurologic dysfunction; active psychological and/or psychiatric conditions and/or social behaviors that prevent adherence to a complex medical regimen; active substance abuse.

Candidates with a history of malignancy with a moderate to high risk of recurrence (as determined after consultation with an oncologist considering tumor type, response to therapy, and presence or absence of metastatic disease) may be unsuitable candidates for transplantation. Patients with low risk of recurrence may be considered.

Prior Authorization

Prior Authorization and Provider Actions

Preauthorization is required for the listed transplant-related CPT codes and prior authorization documentation must demonstrate that conservative management was attempted and failed where clinically appropriate. Refer patients for transplant evaluation only after documenting completion of recommended conservative management (e.g., optimized medical therapy, infection control, substance abuse treatment, smoking cessation, nutritional optimization, weight-loss interventions when indicated) and meeting social support and caregiver requirements. Candidates with a history of substance abuse must demonstrate at least six (6) months of abstinence and formal evaluation by a substance abuse program; thoracic organ candidates must have six (6) months tobacco abstinence as documented and monitored. Failure to provide required preauthorization, documentation of conservative management, or evidence addressing denial-risk conditions (active uncontrolled infection, uncontrolled hypertension, ongoing substance abuse, significant irreversible disease) may result in denial of referral or authorization.

Prior Authorization Required: preauthorization required for transplant-related CPT codes (provider must submit supporting documentation).
Conservative Management Required: documentation of attempted conservative therapies (optimized medical management, infection control, substance abuse treatment, smoking cessation, nutritional/weight-loss interventions) prior to referral.
Denial-risk Conditions: active uncontrolled infection, uncontrolled hypertension, ongoing substance abuse, significant irreversible cardiac/pulmonary/vascular disease — absence of adequate documentation may lead to denial.

Evaluation and Center Requirements

Prior Authorization

Evaluation: 12 months intensive endocrinology care + team summary

Provide documentation showing the patient has undergone intensive endocrinology management for at least 12 months prior to consideration for PTA/PAK, and include a final multidisciplinary transplant team summary to support the referral.

Optimally and intensively managed by an endocrinologist for at least 12 months is required before consideration.
Submit the final summary report from the multidisciplinary transplant team when requesting services.

Documentation Required

Center requirements and team documentation

Ensure the patient can travel on short notice to a KP-approved transplant Center of Excellence and submit multidisciplinary transplant team documentation as part of the evaluation for referral.

Patients must be able to travel within short notice to the KP approved transplant Center of Excellence.
Provide the multidisciplinary transplant team final summary report to support evaluation.

Step Therapy

Conservative management: 12-month endocrinology trial required

Confirm the patient has received intensive endocrinology management for at least 12 months before referring for PTA/PAK; this conservative management period is a prerequisite to consideration.

Optimally and intensively managed by an endocrinologist for at least 12 months is a stated indication prerequisite.

Documentation Required

Required documentation: multidisciplinary team final summary

When requesting these services, submit a copy of the final summary report from the multidisciplinary transplant team to support medical necessity for the transplant referral.

Copy of final summary report from multidisciplinary transplant team must be sent to support medical necessity.

Provider Actions — Authorization, Documentation, and Referral

Prior Authorization

Preauthorization required — verify for listed CPT codes

The listed CPT codes are considered medically necessary when the policy criteria are met; verify plan-specific authorization requirements using the Pre-authorization Code Check before scheduling or billing.

Applicable CPT codes: 48550, 48551, 48552, 48554, 48556 are covered when criteria are met.
To verify authorization requirements for a specific code by plan type, use the Pre-authorization Code Check.

Coding — Applicable Procedure Codes

Applicable CPT CodesCPTCovered

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, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery.
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.

Kidney function requirement — PTA/PAK

Kidney function thresholdGFR or 24-hour creatinine clearance > 50 ml/min

Assessment note for borderline functionAn assessment of the effect on renal function of a calcineurin inhibitor may be required for a creatinine clearance or GFR between 50 and 70 ml/min

Accepted measurement methodsAs determined by direct measurement or calculated by an accepted formula (eg, CKD-EPI) refitted without race

Definitions

Pancreas Transplant Alone (PTA) — definition & context

DefinitionPancreas Transplant Alone (PTA) is transplantation of a pancreatic allograft in a patient who does not simultaneously receive a kidney transplant; used primarily in patients with type 1 diabetes to achieve insulin independence.

Primary indicationType 1 diabetes with disabling, potentially life‑threatening complications (eg, brittle diabetes with severe recurrent hypoglycemia, recurrent DKA, or hypoglycemic unawareness requiring constant supervision)

Typical clinical contextMost pancreas transplants are performed with or after kidney transplant due to immunologic and renal function considerations; PTA used when kidney transplant not indicated or patient has sufficient native kidney function.

Background

Pancreas transplantation is used primarily in patients with type 1 diabetes, either as Pancreas Transplant Alone (PTA) or in combination with kidney transplantation. After a successful pancreas transplant many recipients no longer require exogenous insulin, but they require lifelong immunosuppressive therapy and monitoring because of the risk of graft rejection and immunosuppression-related complications. Most pancreas transplants are performed with concurrent kidney transplantation due to immunologic and renal-function considerations, and outcomes for PTA improved after introduction of modern immunosuppressive regimens.

Policy Summary

PayerKaiser Permanente

PolicyPancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRefer patients only after at least 12 months of intensive endocrinology management and submit the multidisciplinary transplant team summary to support medical necessity.

SourceLink

On This Page

OpenPayer

Pancreas Transplant Alone (PTA) and Pancreas After Kidney (PAK) — Coverage Criteria

Coverage Criteria — Pancreas Transplant (PTA / PAK)

Transplant Candidate Selection Criteria

Medical Contraindications

Evaluation and Center Requirements

Provider Actions — Authorization, Documentation, and Referral

Coding — Applicable Procedure Codes

Definitions

Post-Transplant Care and Coverage

Background