G0342 — Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
11.62
Facility
$718.45
Non-Facility
$718.45
Documentation Required
- Not specified in this excerpt (document does not list required clinical documentation).
- Use validated outcome measures to document whether a condition improves or worsens and whether the magnitude of change is clinically significant
- Document clinical outcomes addressing length of life, quality of life, and functional ability to demonstrate net health benefit (balance of benefits and harms)
- Short-term follow-up (30 days) required to monitor for transplant-related complications.
Key Coverage Criteria
- Autologous pancreatic islet cell transplantation is consideredmedically necessaryas an adjunct to a total or near total pancreatectomy for individuals with chronic pancreatitis.
- Autologous pancreas islet transplantation as an adjunct to total or near‑total pancreatectomy in individuals with chronic pancreatitis.
- Autologous islet transplantation performed at the time of pancreatectomy for chronic pancreatitis to reduce the likelihood of postoperative insulin-dependent diabetes.
- Allogeneic islet transplantation for patients with type 1 diabetes who have frequent and severe metabolic complications and who have consistently failed to achieve glycemic control with insulin-based management.
- Considered as an alternative to whole-organ pancreas transplantation for the above patient population.
- Treatment of type 1 diabetes in adults who cannot achieve target hemoglobin A1c due to repeated episodes of severe hypoglycemia despite intensive diabetes management and education.
7 Active Policies
ANTHEM-MP-A053822 — TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation
BCBSIL-SUR703.057 — Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes
BCBSMT-SUR703.057 — Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes
BCBSNM-SUR703.057 — Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes
BCBSOK-SUR703.057
Related Codes
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