50370
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
18.41
Facility
$1170.03
Non-Facility
$1170.03
Documentation Required
- Documentation of evaluation and acceptance by the facility’s transplant center committee.
- For patients age ≥2 years, documented calculated creatinine clearance or eGFR value showing ≤20 ml/min when applicable.
- For ESRD indication, documentation of dialysis dependence.
- For patients age <2 years, documentation supporting diagnosis of CKD, failing allograft, or ESRD.
Key Coverage Criteria
- Kidney transplant alone (living or deceased donor) may be medically necessary for carefully selected candidates.
- Patients age ≥2 years: Evaluation and acceptance by the facility’s transplant center committee AND chronic kidney disease (CKD) with calculated creatinine clearance or eGFR ≤20 ml/min.
- Patients age ≥2 years: Evaluation and acceptance by the facility’s transplant center committee AND failing kidney transplant allograft with calculated creatinine clearance or eGFR ≤20 ml/min.
- Patients age ≥2 years: Evaluation and acceptance by the facility’s transplant center committee AND end-stage renal disease (ESRD) dependent on dialysis.
- Patients age <2 years: Evaluation and acceptance by the facility’s transplant center committee AND CKD.
- Patients age <2 years: Evaluation and acceptance by the facility’s transplant center committee AND failing kidney transplant allograft.
5 Active Policies
BCBSIL-SUR703.007 — Kidney Transplant
BCBSMT-SUR703.007 — Kidney Transplant
BCBSNM-SUR703.007 — Kidney Transplant
BCBSOK-SUR703.007 — Kidney Transplant
SUR703.007 — Kidney Transplant
Related Codes
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