Pancreas Transplantation

This policy covers pancreas transplantation (simultaneous pancreas‑kidney [SPK], pancreas after kidney [PAK], pancreas transplant alone [PTA]) and selected islet cell procedures (including autologous islet transplantation with total/near‑total pancreatectomy) to restore glucose‑regulated insulin secretion, halt diabetes‑related complications, and improve quality of life. Coverage is limited to insulin‑requiring, typically type 1 or labile diabetic patients who meet specified criteria (e.g., PTA candidates managed by an endocrinologist ≥12 months; SPK for ESRD or impending dialysis; PAK with stable kidney function CrCl ≥30 mL/min) and excludes those with listed contraindications such as uncontrolled infection, recent MI/stroke, high‑risk malignancy, inadequate GFR (<40 mL/min/1.73 m² unless for multi‑organ transplant), uncontrolled HIV, active substance use/tobacco without risk‑reduction, inability to adhere to post‑transplant care, re‑transplantation after ≥2 failed pancreas grafts, and does not support allogeneic islet or xenotransplantation.