OAR 410-124-0120
Criteria and Contraindications for Simultaneous Pancreas-Kidney and Pancreas After Kidney Transplants
(1)
Prior authorization for a Simultaneous Pancreas-Kidney (SPK) or Pancreas after Kidney (PAK) transplant will be approved only for a client in whom irreversible kidney and/or pancreatic disease has advanced to the point where conventional therapy offers no prospect for prolonged survival, there is no reasonable alternative medical or surgical therapy and the client’s five (5) year survival rate, subsequent to the transplant, is at least 20 percent as supported by medical literature.(2)
Simultaneous pancreas-kidney (SPK) transplant is covered only for Type I diabetes mellitus with end stage renal disease (ICD-10-CM codes E10.21, E10.22, E10.29, E10.21, E10.65).(3)
Pancreas after kidney (PAK) transplantation will be considered for clients suffering from insulin dependent Type I diabetes after prior successful renal transplant. Pancreas after kidney (PAK) transplant is covered only for Type I diabetes mellitus (ICD-10-CM codes E10.8-E10.11, E10.31, E10.36, E10.39-E10.40-E10.41, E10.44, E10.49, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.349, E10.351, E10.359, E10.610, E10.618, E10.620-E10.622, E10.628, E10.630, E10.638-E10.649, E10.69, T86.10-T86.13, T86.19, T86.890-T86.92, T86.898-T86.99(4)
The following are contraindications to SPK and PAK transplants:(a)
Uncorrectable severe coronary artery disease;(b)
Major irreversible disease of any other major organ system likely to limit life expectancy to five years or less;(c)
HIV positive test results.(5)
The following may be considered contraindications to the extent that the evaluating transplant center and/or the specialist who completed the comprehensive evaluation of the client believe these condition(s) may interfere significantly with the recovery process:(a)
Serious psychological disorders;(b)
Drug abuse or alcohol abuse.(6)
The Division of Medical Assistance Programs (Division) will only prior authorize and reimburse for Simultaneous Pancreas-Kidney (SPK) or Pancreas after Kidney (PAK) transplants if:(a)
All Division criteria are met; and(b)
Both the transplant center’s and the specialist’s evaluations recommend that the transplant be authorized; and(c)
The ICD-10-CM diagnosis code(s) and CPT transplant procedure code(s) are paired on the same currently funded line on the Prioritized List of Health Services adopted under OAR 410-141-0520.
Source:
Rule 410-124-0120 — Criteria and Contraindications for Simultaneous Pancreas-Kidney and Pancreas After Kidney Transplants, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-124-0120.