Allogeneic Pancreas Transplant

Covers allogeneic pancreas transplantation — including simultaneous pancreas–kidney (SPK), pancreas-after-kidney (PAK), pancreas-alone, and selected pancreatic retransplantation — to restore glucose control and treat complications in patients with insulin‑dependent diabetes mellitus (IDDM). Coverage is limited to patients who meet specified clinical criteria (e.g., SPK for IDDM with uremia; pancreas‑alone for refractory severe hypoglycemia unawareness or life‑threatening labile diabetes), excludes transplants performed in or using organs from countries designated for forced organ harvesting (e.g., China) and certain experimental procedures (e.g., pancreatic segment donation), disallows retransplantation after two or more failed pancreas transplants, and is subject to standard contraindications (active malignancy, uncontrolled infection, significant psychosocial/substance‑use issues).

"Allogeneic pancreas transplant may be considered medically necessary when specific clinical indications or criteria (not specified in this excerpt) are met."