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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-50300-01

Original Effective Date: 01/01/01

Reviewed: 07/24/14

Revised: 08/15/14

Subject: Kidney Transplantation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    

DESCRIPTION:

A kidney transplant involves the surgical removal of a kidney from a cadaver, living-related, or living-unrelated donor and transplantation into the recipient.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Kidney Transplantation to expedite the medical review process.

1. Click the link Solid Organ Transplant - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Kidney transplant with either a living or cadaver donor meets the definition of medical necessity for carefully selected candidates with end-stage renal disease.

Etiologies of end-stage renal disease include, but are not limited to, any of the following conditions associated with end-stage renal disease:

Kidney transplant with either a living or cadaver donor meets the definition of medical necessity in HIV [human immunodeficiency virus]-positive candidates who meet ALL of the following:

Kidney retransplant after a failed primary kidney transplant meets the definition of medical necessity in individuals who meet criteria for kidney transplantation.

Kidney transplant is considered experimental or investigational in all other situations.

Potential contraindications to kidney transplant (subject to the judgment of the transplant center) include:

Transplant associated services which meet the definition of medical necessity include:

BILLING/CODING INFORMATION:

CPT Coding:

50300

Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral

50320

Donor nephrectomy (including cold preservation); open, from living donor

50323

Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary

50325

Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary

50327

Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each

50328

Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each

50329

Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each

50340

Recipient nephrectomy (separate procedure)

50360

Renal allo-transplantation; implantation of graft; without recipient nephrectomy

50365

With recipient nephrectomy

50547

Donor nephrectomy (including cold preservation), from living donor

REIMBURSEMENT INFORMATION:

Please refer to the specific contractual agreements with the applicable transplant facility or to the global rates of the applicable transplant network.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Anastomosis: a connection between two vessels or organs.

ESRD: end stage renal disease.

Iliac fossa: a large, smooth concave area occupying much of the inner surface of the ala of the ilium, especially anteriorly; from it arises the iliacus muscle.

Nephritis: inflammation of the kidney.

Nephropathy: disease of the kidneys.

Renal failure: kidney failure.

Ureteropyelostomy: (ureteropyeloneostomy) the surgical formation of a new passage from the pelvis of a kidney to the ureter.

RELATED GUIDELINES:

Pancreas Transplantation, 02-40000-17

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. NCG-7338: Guidelines on renal transplantation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar.
  2. AHRQ National Guideline Clearinghouse. NCG-7339: Transplantation techniques. In: Guidelines on renal transplantation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar.
  3. American Medical Association CPT (current edition)
  4. American Society of Transplant Surgeons. Statement on Paired Kidney Donation. Accessed 05/09/08.
  5. American Society of Transplantation (AST): Key Position Statements. Accessed 06/08/09.
  6. American Society of Transplant Surgeons (ASTS), The American Society of Transplantation, The Association of Organ Procurement Organizations (AOPO) and the United Network for Organ Sharing (UNOS),. Position Statement on Transplantation of Organs from HIV-infected deceased donors. 2011. Accessed at http://asts.org on 06/25/14.
  7. Benaragama SK, Tymkewycz T, John BJ, Davenport A, Lindsey B, Nicol D, Olsburgh J, Drage M, Mamode N, Calder F, Taylor J, Koffman G, Kessaris N, Morsy M, Cacciola R, Puliatti C, Fernadez-Diaz S, Syed A, Hakim N, Papalois V, Fernando BS. Do we need a different organ allocation system for kidney transplants using donors after circulatory death? BMC Nephrol. 2014 May 22;15:83.
  8. Bhagani S, Sweny PL, Brook G. (2006). Guidelines for kidney transplantation in patients with HIV disease. British HIV Association. HIV medicine, 7(3), 133-139.
  9. Blue Cross Blue Shield Association Medical Policy – Kidney Transplant 7.03.01 (June 2014)
  10. Blue Cross Blue Shield Association TEC Evaluations (August 1988)
  11. Chapman JR. What are the key challenges we face in kidney transplantation today? Transplant Res. 2013 Nov 20;2(Suppl 1):S1.
  12. ECRI Institute Health Technology Forecast: New Donor Kidney Allocation Policy Projected to Extend Patient and Organ Survival. May 20, 2014.
  13. Kim JJ, Marks SD. Long-term outcomes of children after solid organ transplantation. Clinics (Sao Paulo). 2014 Jan;69 Suppl 1:28-38.
  14. Mazuecos A, Fernandez A, Andres A et al. HIV infection and renal transplantation. Nephrol Dial Transplant 2011; 26(4):1401-7.
  15. Medicare Benefit Policy Manual. Chapter 11- End Stage Renal Disease (ESRD).Accessed at http://www.cms.gov/manuals/Downloads/bp102c11.pdf on 06/25/14.
  16. Segev DL, Muzaale AD, Caffo BS et al. Perioperative mortality and long-term survival following live kidney donation. JAMA 2010; 303(10):959-66.
  17. St. Anthony’s ICD-9-CM Code Book (current edition)
  18. Stock PG, Barin B, Murphy B et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010; 363(21):2004-14.
  19. Thierry A, Mourad G, Büchler M, Choukroun G, Toupance O, Kamar N, Villemain F, Le Meur Y, Legendre C, Merville P, Kessler M, Heng AE, Moulin B, Queré S, Di Giambattista F, Lecuyer A, Touchard G. Three-year outcomes in kidney transplant patients randomized to steroid-free immunosuppression or steroid withdrawal, with enteric-coated mycophenolate sodium and cyclosporine: the infinity study. Transplant. 2014;2014:171898.
  20. Trullas JC, Cofan F, Tuset M et al. Renal transplantation in HIV-infected patients: 2010 update. Kidney Int 2011; 79(8):825-42.
  21. UK Renal Association Clinical Practice Guidelines. Assessment of the Potential Kidney Transplant Recipient. Accessed at http://www.renal.org on 06/25/14.
  22. U.S. Department of Health and Human Services Organ Procurement and Transplantation Network. Accessed at http://optn.transplant.hrsa.gov on 06/25/14.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/24/14.

GUIDELINE UPDATE INFORMATION:

01/01/01

Medical Coverage Guideline reformatted.

12/15/02

Reviewed and revised; statement added regarding transplant facilities.

11/15/04

Scheduled review; added statement regarding transplants in HIV+ recipients.

01/01/05

HCPCS coding update: added new renal transplant codes; revised descriptors for 50300, 50320, and 50360.

06/15/05

Revision of guideline, consisting of removal of investigational statement regarding HIV-positive recipients.

06/15/06

Scheduled review; no change in coverage statement.

06/15/07

Scheduled review (consensus); no change in coverage statement; reformatted guideline; updated references.

07/15/08

Scheduled review; no change in position statement. Updated references.

07/15/09

Scheduled review; no change in position statement. Updated references.

10/15/10

Revision; related ICD-10 codes added.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

05/11/14

Revision: Program Exceptions section updated.

08/15/14

Scheduled review. Revised description, position statement and program exceptions section. Updated references.

Date Printed: August 18, 2017: 10:27 AM