Pancreas Kidney Transplantation

Aetna covers simultaneous pancreas‑kidney (SPK) and simultaneous pancreas cadaver‑kidney or living‑donor kidney (SPLK) transplantation as medically necessary for patients with diabetes and end‑stage renal disease who meet the transplant center’s selection criteria — or, if the center has no criteria, when Cockcroft‑Gault creatinine clearance <20 ml/min or measured GFR <20 ml/min AND the member requires dialysis or is expected to require dialysis within 12 months (specified CPT/ICD‑10 codes apply). Transplants are not medically necessary for poorly controlled HIV (detectable viral load, not on stable ART ≥3 months, opportunistic infections/neoplasms, or CD4 <200/not ≥200 for ≥6 months), for listed absolute contraindications (e.g., inability to adhere, most active malignancies, untreated/recurrent infections, persistent substance abuse, severe uncorrectable cardiac disease, unresolvable psychosocial problems), and certain approaches (IGL‑1 preservation solution, donor‑derived cell‑free DNA monitoring) are experimental/not covered.