48554
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
36.86
Facility
$2560.85
Non-Facility
$2560.85
Documentation Required
- Documentation that the member meets the transplanting institution's selection criteria; OR if no institution criteria exist, documentation that both required numeric criteria are met: calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min, AND documented ESRD with current dialysis or expectation of requiring dialysis within the next 12 months.
- Record of the Cockcroft-Gault calculation inputs (age, weight in kg, serum creatinine in mg/dL) or directly measured GFR values to support creatinine clearance/GFR determination.
- For HIV-positive members: documentation of HIV-1 RNA (viral load) status (undetectable required), documentation of duration of stable antiretroviral therapy (≥ 3 months required), documentation of absence of opportunistic infections or neoplasms, and CD4 counts showing ≥ 200 cells/mm3 for at least 6 months.
Key Coverage Criteria
- Simultaneous pancreas-kidney (SPK) transplantation is medically necessary for members with diabetes and end-stage renal disease (ESRD) who meet the transplanting institution's selection criteria.
- Aetna considers SPK and SPLK transplantation medically necessary for persons with certain relative contraindications if the attending physician determines and documents that the potential benefits of SPK or SPLK transplantation outweigh the risks (relative contraindications listed separately).
- CPT/HCPCS/Coding context: Specific CPT codes (e.g., 48554 Transplantation of pancreatic allograft; 50360 Renal allotransplantation; donor nephrectomy codes 50300/50320/50547; and others listed) and HCPCS S2065 (Simultaneous pancreas kidney transplantation) are listed as covered if selection criteria are met.
- ICD-10 diagnoses listed as covered if selection criteria are met: E10.21 - E10.29; E11.21 - E11.29; E13.21 - E13.29 (Diabetes mellitus with renal manifestations); N18.5 (Chronic kidney disease, Stage V); N18.6 (End stage renal disease).
- Simultaneous cadaver-donor pancreas and living-donor kidney (SPLK) transplantation is medically necessary for members with diabetes and ESRD who meet the transplanting institution's selection criteria.
- If a transplanting institution has no selection criteria, SPK or SPLK is medically necessary when ALL of the following are met: (1) calculated creatinine clearance (Cockcroft-Gault) < 20 ml/min OR directly measured GFR < 20 ml/min; AND (2) member has ESRD and requires dialysis or is expected to require dialysis in the next 12 months.
9 Active Policies
AMBETTER-CP.MP.102 — Pancreas Transplantation
AETNA-CPB-0587 — Pancreas Kidney Transplantation
ANTHEM-MP-A046252 — Pre-Merger Organizations
BCBSIL-SUR703.013 — Allogeneic Pancreas Transplant
BCBSMT-SUR703.013 — Allogeneic Pancreas Transplant
Related Codes
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