Pediatric Kidney Transplant

This policy covers pediatric kidney transplantation and associated evaluation/management—including preemptive/transplant listing—for children <18 with advanced CKD/ESRD (notably GFR <15 mL/min/1.73 m² or CKD stage 4 with GFR <30 mL/min/1.73 m² expected to progress), and other indications (congenital/hereditary kidney disease, growth failure) per KDIGO 2020 and OPTN guidance. Coverage is limited to non‑Medicare pediatric members and requires multidisciplinary, guideline‑based candidacy assessment; exclusions/contraindications include active untreated infections (HCV managed per KDIGO guidance is permitted), uncontrolled HIV, active high‑risk malignancy, recent major cardiovascular/cerebrovascular events, unmanaged cardiac or peripheral vascular disease, ongoing substance use or inability to adhere, decompensated cirrhosis unless eligible for combined transplant, and other KDIGO/OPTN‑listed contraindications, with state Medicaid rules taking precedence where applicable.