48550
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Refer to separate policy CP.MP.250 for criteria related to Lantidra (donislecel) allogeneic pancreatic islet cellular therapy.
- Serial blood and urine testing may be required to verify abstinence from substances of concern.
- Documentation of a commitment to reduce substance-use behaviors is acceptable when urgent transplant timelines exist (as evidence of risk-reduction intent).
- Chart notes, emergency department records, or hospitalization records documenting the recurrent severe metabolic complications and specifying the type (e.g., hypoglycemia unawareness, severe hypoglycemic attacks, marked hyperglycemia, recurrent ketoacidosis).
Key Coverage Criteria
- Note:Members must meet the disease specific criteria as well as the General Individual Selection criteria below for the transplantation to be considered medically necessary.
- Simultaneous deceased-donor pancreas/kidney transplant (SPK) is consideredmedically necessaryfor individuals with insulin dependent diabetes mellitus (IDDM) who have end-stage renal disease.
- Simultaneous deceased-donor pancreas and living-donor kidney transplant (SPLK) is consideredmedically necessaryfor individuals with insulin dependent diabetes mellitus who have end-stage renal disease.
- Pancreas transplant alone (PTA) either deceased or living-donor segmental is consideredmedically necessaryfor individuals who have insulin dependent diabetes mellitus with severe disabling and documented life threatening hypoglycemic unawareness due to labile diabetes which persists despite optimal medical management.
- Pancreas after kidney transplant (PAK) is consideredmedically necessaryfor individuals with insulin dependent diabetes mellitus.
- One pancreas alone, one pancreas after kidney or one simultaneous pancreas/kidney (SPK or SPLK) re-transplantation after failure of the primary graft is consideredmedically necessaryprovided the individual meets the transplant criteria above.
8 Active Policies
AMBETTER-CP.MP.102 — Pancreas Transplantation
ANTHEM-MP-A046252 — Pre-Merger Organizations
BCBSIL-SUR703.013 — Allogeneic Pancreas Transplant
BCBSMT-SUR703.013 — Allogeneic Pancreas Transplant
BCBSNM-SUR703.013 — Allogeneic Pancreas Transplant
Related Codes
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