CurrentKaiser PermanentePolicy N/A

Simultaneous Pancreas and Kidney (SPK) Transplant Referral and Coverage Criteria

Defines Kaiser Permanente clinical review criteria, referral guidelines, contraindications, and applicable procedure codes for simultaneous pancreas-kidney transplantation for Kaiser Permanente Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicySimultaneous Pancreas and Kidney (SPK) Transplant Referral and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit the multidisciplinary transplant team final summary and supporting documentation when requesting SPK transplant services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18-55Age range

<28BMI threshold

6 monthsAbstinence period

<20 mL/mineGFR listing

MultipleProcedure codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

SPK Transplant Coverage Criteria

Covered when ALL of the following are met:

SPK Candidate General Requirements: Candidate must be suitable for kidney transplantation and meet general transplant candidate principles including adequate social support, adherence, caregiver availability, and ability to travel to KP approved Center of Excellence

See General Principles section for specifics on social support, adherence, caregiver, and travel requirements

Diabetes and Endocrine Criteria: Type 1 diabetes, or select Type 2/1.5 diabetes confirmed by low stimulated C-peptide or diabetes autoantibodies; optimally and intensively managed by an endocrinologist for at least 12 months12 months endocrine management

Type 1.5 diagnosis may require endocrinology input and stimulated C-peptide or antibody testing

Age and Physiologic Criteria: Age generally 18-55 unless special circumstances; BMI considerations apply (select Type 2 candidates <28; BMI ≥35 is a relative contraindication) and must meet kidney transplant candidacy including eGFR thresholds for listingAge 18-55; BMI <28 for select Type 2; eGFR <20 mL/min for listing

Exceptions may be considered case-by-case

Contraindications and Risk Factors: No uncontrolled active infection, no significant irreversible coronary or pulmonary disease, no uncontrolled hypertension, and substance/tobacco abstinence for 6 months when required; history of malignancy with moderate/high recurrence risk may be unsuitable6 months tobacco/substance abstinence

Specific programs may require tobacco abstinence to be actively listed; active infection must be resolved prior to referral/listing

The policy lists specific clinical exclusions related to major organ disease that preclude simultaneous pancreas-kidney (SPK) transplantation. Notable exclusions include significant irreversible coronary disease or left ventricular dysfunction, irreversible pulmonary disease, and irreversible peripheral vascular disease (including carotid vascular disease). Amputation alone is not considered a contraindication. Additionally, uncontrolled hypertension is identified as a clinical contraindication and should be addressed before considering transplant candidacy.

Candidates with ongoing active infection, recent substance abuse, or significant social or psychological barriers are generally not suitable for SPK transplant referral. The policy specifies that uncontrollable active infection is a contraindication. Candidates with a history of substance abuse must demonstrate at least 6 months of abstinence and have been evaluated by a substance abuse program. Adequate social support, demonstrated adherence, caregiver availability, and the ability to travel to a KP approved Center of Excellence are required; active psychological, psychiatric, or social behaviors that prevent adherence are considered contraindications.

Candidate Evaluation Criteria and Eligibility

SPK Candidate Evaluation Criteria

Referral for transplant evaluation is recommended when clinical parameters indicate end-stage disease and the candidate meets the general principles below:

General candidate requirements: Adequate social support, documented adherence history, caregiver availability able to travel to KP approved Center of Excellence, tobacco/substance abstinence when required, and resolution of active infection6 months; infection resolved

Evidence of nonadherence includes missed appointments, failure to complete evaluation, and medication nonadherence

Diabetes-specific: Type 1 diabetes or select Type 2 (Type 1.5) defined by low stimulated C-peptide or presence of diabetes autoantibodies (eg, GAD, islet cell, insulin); managed and optimized by endocrinology for at least 12 months12 months

Type verification via stimulated C-peptide or antibody testing; endocrinology involvement may be required

Kidney transplant candidacy: Patient must be an appropriate candidate for kidney transplantation and meet eGFR listing thresholds using CKD-EPI equations refitted without raceeGFR <20 mL/min

Patients cannot be listed for a deceased donor kidney until eGFR threshold met

Contraindications

Clinical conditions that should lead to denial or deferral of SPK transplantation include uncontrollable active infection, significant irreversible coronary disease or left ventricular dysfunction, irreversible pulmonary disease, and irreversible peripheral vascular disease (including carotid vascular disease). Uncontrolled hypertension is also listed as a contraindication. Additionally, candidates lacking adequate social support, with active substance abuse without documented abstinence, or with active psychological/psychiatric conditions that would prevent adherence should be considered unsuitable and may be denied or deferred until these issues are resolved.

Pre-Transplant Evaluation Requirements

Prior Authorization

Prior Authorization Required

Provider must obtain preauthorization for all listed transplant procedure codes prior to scheduling the transplant. Submit the member's pre-transplant evaluation packet and proposed procedure codes to Kaiser Permanente preauthorization as required by the payer. Failure to obtain prior authorization may result in claim denial or delayed authorization.

Preauthorization required for all transplant procedure CPT/HCPCS codes being requested

Denial Risk

Denial Triggers (Clinical Contraindications)

Transplants may be denied when clinical contraindications are present. Document and verify absence of the following denial triggers prior to authorization: active substance use disorder without documented period of treatment/abstinence per program standards; active, uncontrolled infection; significant psychosocial barriers (including lack of adequate social support or inability to adhere to post-transplant regimen); active malignancy without documented cancer-free interval per specialty guidelines; or other organ-specific contraindications identified by the Center of Excellence (COE). If any contraindication exists, do not submit for authorization until resolved and documented.

Denial triggers include active substance use, uncontrolled infection, active malignancy without required disease-free interval, significant psychosocial barriers, and other organ-specific contraindications

Note

Staged Transplant Pathway — COE Recommendations

For multiorgan and staged transplant planning, the NTS Center of Excellence (COE) may recommend staged procedures (for example: living donor kidney transplant followed later by cadaveric pancreas transplant) based on organ availability and clinical appropriateness. When a staged pathway is recommended, the patient must meet all indications and evaluation requirements for the intended final transplant strategy (for example, indications for simultaneous pancreas-kidney [SPK] when that is the anticipated pathway). Ensure documentation from the COE outlining the staged plan is included with authorization requests.

Operational note: living donor kidney then cadaveric pancreas — patient must meet SPK indications if SPK is the planned final pathway

Provider Actions, Authorization and Documentation

Prior Authorization

Preauthorization required for listed transplant procedure codes

Authorization is required for the listed transplant procedure CPT/HCPCS codes; verify plan-specific preauthorization requirements by plan type before scheduling.

Use the Pre-authorization Code Check to confirm requirements for the member's plan and code.
Applicable codes include multiple renal and pancreas transplant CPTs and HCPCS S2065 as listed in the policy.

Documentation Required

Required documentation: multidisciplinary transplant team summary

Submit a final summary report from the multidisciplinary transplant team and supporting documentation to justify medical necessity when requesting authorization or listing.

Include the multidisciplinary team’s final summary report with the authorization request.

Denial Risk

Denial triggers: clinical contraindications and social/support risks

Candidates with uncontrolled active infection, active substance abuse without six months’ abstinence, significant irreversible organ disease, or inadequate social/support resources are likely to be deemed unsuitable and may be denied.

Uncontrollable active infection is a contraindication to transplant.
Active substance abuse without 6 months abstinence or lack of substance‑abuse program evaluation may trigger denial.
Significant irreversible coronary, pulmonary, or peripheral vascular disease are exclusionary risks.
Insufficient social support, inability to adhere to complex regimens, or lack of caregiver/travel ability may render candidate unsuitable.

Note

Center requirements: KP approved Transplant Center of Excellence and travel/caregiver capability

Referral and listing must be to a Kaiser Permanente–approved Transplant Center of Excellence; caregivers and the patient must be willing and able to travel at short notice to that KP approved Center of Excellence.

Ensure referrals and listings are directed to KP approved Transplant Center of Excellence.
Confirm caregiver(s) are physically/cognitively able and can travel on short notice to the KP Center of Excellence.

Procedure and Billing Codes

Renal transplant and donor procedure CPT codesCPTCovered

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 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 prior.
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 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.
50340	Recipient nephrectomy (separate procedure).
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy.
50365	Renal allotransplantation, implantation of graft; with recipient nephrectomy.

1–10 of 13

1/2

Pancreas transplant 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.
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.

HCPCS / other transplant codesHCPCS

S2065

Simultaneous pancreas kidney transplantation (HCPCS code) *codes not covered by Medicare

inv-07: BMI — thresholds and notes

BMI threshold for select Type 2/Type 1.5 candidatesBMI < 28 for selective Type 2 (Type 1.5) patients with low C‑peptide who require low‑dose insulin and have end‑stage renal disease

Relative contraindicationBMI ≥ 35 is noted as a relative contraindication and may be considered case‑by‑case

Clinical contextBMI criteria are applied in conjunction with diabetes type verification (stimulated C‑peptide or antibody testing) and endocrinology assessment

inv-08: Age — typical candidate age range and exceptions

Typical candidate age rangeAge 18–55 is the usual range for SPK candidates

ExceptionsPatients outside 18–55 may be considered under special clinical circumstances

Relation to other criteriaAge requirement is applied alongside diabetes, BMI, and kidney transplant candidacy criteria

inv-09: eGFR for listing — estimated GFR threshold

eGFR threshold for deceased donor kidney listingEstimated GFR (CKD‑EPI creatinine 2021 refitted without race or CKD‑EPI creatinine‑cystatin 2012 refitted without race) < 20 mL/min before listing

Requirement to be candidate for kidney transplantMust be a candidate for kidney transplantation to be eligible for SPK listing

Calculation methodUse CKD‑EPI equations refitted without race as specified in policy

Definitions and Special Case Eligibility

inv-15: Type 1.5 Diabetes Mellitus (Type 2 patients eligible) — selection criteria

C‑peptide and antibodiesType verification via stimulated C‑peptide testing or diabetes autoantibodies (GAD, islet cell, insulin) may be required to identify Type 1.5 patients

BMI requirement for Type 1.5/Type 2 eligibilitySelect Type 2 (Type 1.5) patients considered for SPK typically have low BMI (<28)

Insulin requirementCandidates are those requiring low‑dose insulin despite low C‑peptide and low BMI

Endocrinology optimizationPatients should be optimally and intensively managed by an endocrinologist for at least 12 months prior to consideration

Background

Simultaneous pancreas-kidney (SPK) transplantation is an option for diabetic patients who are candidates for kidney transplant and may improve outcomes beyond renal replacement therapy in selected patients. Candidate selection requires confirmation of diabetes type (including consideration of select Type 2 or “Type 1.5” patients), endocrinology optimization for at least 12 months, and suitability for kidney transplantation. The evaluation balances potential benefits of restoring endocrine and renal function against the risks of major surgery and lifelong immunosuppression, and requires multidisciplinary assessment and adequate social support.