Z48.298 — Encounter for aftercare following other organ transplant
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical documentation must show the transplant met Medicare coverage criteria in effect at the time, including facility approval status and applicable national/local medical necessity determinations.
- Beneficiary enrollment must be documented: Medicare Part A enrollment at time of transplant and Medicare Part B enrollment at time of drug dispensing.
- For pancreas-transplant-alone candidates, documentation must include type 1 diabetes diagnosis, beta-cell autoantibody status or fasting C‑peptide with a concurrently obtained fasting glucose, history of labile insulin-dependent diabetes with documented recurrent severe metabolic complications requiring hospitalization, and 12 months of endocrinologist-managed intensive care with advanced insulin therapies.
- For pancreatic islet cell or partial pancreatic tissue transplants, documentation must demonstrate the procedure was part of an NIH-sponsored clinical trial to qualify for Medicare-covered routine costs including immunosuppressive drugs.
Key Coverage Criteria
- Immunosuppressive drugs are covered when prescribed following a covered organ transplant of kidney, heart, liver, bone marrow/stem cell, lung, or combined heart-lung.
- Immunosuppressive drugs are covered after a whole-organ pancreas transplant that was performed concurrent with or subsequent to a kidney transplant for diabetic nephropathy when the transplant was performed on or after 1999-07-01.
- Immunosuppressive drugs are covered after an intestinal transplant performed on or after 2001-04-01.
- Immunosuppressive drugs are covered after pancreatic islet cell transplantation or partial pancreatic tissue transplantation performed on or after 2004-10-01 only when the procedure is conducted as part of an NIH-sponsored clinical trial (Medicare covers routine costs including immunosuppressive drugs).
- Immunosuppressive drugs are covered after a pancreas transplant alone performed on or after 2006-04-26 if the transplant facility is Medicare-approved for kidney transplantation.
- For pancreas-transplant-alone recipients, immunosuppressive drugs are covered only if beneficiary has type 1 diabetes and is beta cell autoantibody positive.
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