Pre-Merger Organizations

This policy addresses pancreas transplantation procedures, including pancreas transplant alone (PTA), pancreas after kidney (PAK), and combined pancreas-kidney transplants (SPK/SPLK). Coverage is medically necessary when criteria are met: SPK or SPLK for individuals with insulin-dependent diabetes mellitus (IDDM) and end-stage renal disease; PTA (deceased or living-donor segmental) for IDDM with severe, disabling, life-threatening hypoglycemic unawareness despite optimal management; and PAK for IDDM per disease-specific criteria—provided members also meet general selection criteria and have no AST-defined contraindications. Pancreas transplantation is investigational/not medically necessary for all other indications and for any third or subsequent pancreas-related transplant; multi-organ transplant requests must meet criteria for each organ and may be reviewed individually.

"Note:Members must meet the disease specific criteria as well as the General Individual Selection criteria below for the transplantation to be considered medically necessary."