Pediatric Kidney Transplant
Customize your policy alerts
Sign up for mhn Policy CP.MP.246 alerts
Get alerted when Policy CP.MP.246 changes without checking for updates manually.
Monitor payer policy activity
Medical necessity criteria and coverage guidance for pediatric (age <18) kidney transplantation for non‑Medicare health plans affiliated with Centene, including candidate eligibility and contraindications.
Criteria I.A.1. updated from GFR ≤ 15 mL/min/1.73 m2 to GFR < 15 mL/min/1.73 m2 to align with KDIGO and OPTN guidance.
Criteria I.A.2. updated to include CKD stage 4 with GFR < 30 mL/min/1.73 m2 in members expected to reach ESRD.
Contraindication I.B.2 for HIV infection clarified to require CD4 >200 cells/mm3, absence of active AIDS-defining opportunistic infection, and effective ART.
Policy specifies that it applies to non‑Medicare health plans and refers Medicare criteria to a separate Medicare policy (MC.CP.MP.246).
Coverage and Medical Necessity Criteria
Initial transplant candidacy
Covered when ALL of the following are met:
Primary eligibility
- Advanced renal disease: One of: ESRD (stage 5) with GFR < 15 mL/min/1.73 m2 OR CKD stage 4 with GFR < 30 mL/min/1.73 m2 in those expected to reach ESRD
- No contraindications: Does not have any contraindication from list I.B
Patients with decompensated cirrhosis are excluded from pediatric kidney transplantation under this policy, unless they are evaluated and listed as candidates for a combined liver–kidney transplant.
Transplantation is considered not medically necessary when the candidate has any of the listed active or uncontrolled conditions. Examples include active untreated infection (except treated hepatitis C where applicable), uncontrolled HIV (see HIV-specific control criteria), active malignancy with high risk of recurrence or death, recent stroke or transient ischemic attack within specified timeframes, active symptomatic cardiac or peripheral arterial disease that is unevaluated or unmanaged, inability to adhere to required post‑transplant regimens, active substance use disorder affecting decision‑making, recent acute pancreatitis within 3 months, or elevated circulating anti‑GBM antibodies.
Candidate Selection Criteria
Candidate selection criteria
Candidate eligibility requires meeting renal function thresholds and absence of contraindications.
Absolute and Relative Contraindications
Contraindications that preclude transplantation include: active infection that is not properly treated (except hepatitis C), HIV infection with detectable viral load unless the candidate meets all three control criteria (CD4 > 200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and evidence of being on effective antiretroviral therapy), active malignancy with high risk of recurrence or mortality, stroke within the past 6 months or transient ischemic attack within the past 3 months, 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 increases post‑transplant risk, acute pancreatitis within the last 3 months, decompensated cirrhosis (unless a combined liver–kidney transplant candidate), and elevated circulating anti‑glomerular basement membrane antibodies.
Pre-Transplant Evaluation Requirements
Pre‑transplant multidisciplinary evaluation and referral; include procedure codes for authorization
Refer pediatric patients with rapidly progressive CKD or anticipated progression to ESRD for multidisciplinary transplant evaluation to determine the cause of ESRD and suitability for transplantation. The evaluation should follow KDIGO and OPTN guidance and include specialty assessments (for example cardiology clearance when indicated) and documentation of renal function (GFR) thresholds. Providers must obtain prior authorization using the procedure codes referenced in the policy when scheduling donor/allograft procurement or transplantation services.
- Refer patients with GFR <30 mL/min/1.73 m2 who are expected to progress to ESRD for transplant evaluation (CKD stage 4 eligibility context).
- For ESRD (stage 5) document GFR <15 mL/min/1.73 m2.
- Follow multidisciplinary center evaluation per KDIGO/OPTN guidance; obtain cardiology clearance after myocardial infarction when applicable.
- When requesting authorization include the referenced procedure codes (50300, 50320, 50323, 50325, 50327, 50328, 50329, 50360, 50365, 50547, S2152) as applicable to donor procurement, backbench preparation, reconstruction, nephrectomy, implantation, and global transplant services.
Provider Actions, Documentation, and Prior Authorization
Prior authorization and referenced procedure codes
Prior authorization is required per plan procedures for pediatric kidney transplant services; CPT and HCPCS procedure codes referenced in the policy should be used for informational coding guidance when requesting authorization.
No step‑therapy requirement
Step therapy does not apply; transplant candidacy is determined by meeting the clinical criteria in the policy rather than by a stepwise medication or therapy sequence.
Required supporting clinical documentation
Submit clinical documentation demonstrating advanced renal disease using the policy GFR thresholds and evidence that no contraindications from the policy list are present; for candidates with HIV include CD4 >200 cells/mm3, absence of active AIDS‑defining opportunistic infection, and evidence of effective antiretroviral therapy.
- Document GFR consistent with ESRD (GFR < 15 mL/min/1.73 m2) or CKD stage 4 (GFR < 30 mL/min/1.73 m2) when expected to reach ESRD.
- For HIV: include recent CD4 count, documentation of no active AIDS‑defining infection, and current effective ART.
Contraindications that may result in denial
Presence of any listed active or uncontrolled conditions may lead to denial of transplant; ensure these are evaluated, treated, or documented as resolved before authorization.
- Active untreated infection (except treated HCV).
- Uncontrolled HIV without meeting specified control criteria.
- Active malignancy with high risk of recurrence or death.
- Recent stroke (within 6 months) or TIA (within 3 months).
- Active symptomatic cardiac or peripheral arterial disease not evaluated/managed.
- Inability to adhere to post‑transplant regimen, active substance use disorder, recent acute pancreatitis (<3 months), decompensated cirrhosis (unless combined transplant), or elevated anti‑GBM antibodies.
Procedure and Diagnosis Coding
| 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. |
Definitions and Terminology
Transplant Center Expectations
Center capabilities and guideline‑based evaluation
Transplant centers are expected to perform guideline‑based, multidisciplinary evaluation and management per KDIGO and OPTN guidance; centers should have capabilities to evaluate etiology, comorbid conditions, and provide necessary pre‑ and post‑transplant care.
- Evaluation and management recommendations are based on KDIGO 2020 and OPTN educational guidance.
- Centers should assess cause of ESRD, cardiovascular risk, infection status, and other contraindications as part of multidisciplinary evaluation.
Post-Transplant Services and Global Care
Background and Rationale
Kidney transplantation is the preferred treatment option for pediatric patients with advanced CKD and ESRD because it improves survival, quality of life, and growth—benefits that are particularly important in young children and in candidates for preemptive transplant when a living donor is available. A multidisciplinary evaluation should determine the etiology of ESRD and candidacy for transplant, and preemptive living‑donor transplantation is preferred when feasible.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.