Clinical UM Guideline


Subject:Kidney Transplantation
Guideline #:  CG-TRANS-02Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

A kidney transplant involves the removal of the kidney from a deceased or living donor with the implantation into a single recipient.

Note: Please see the following related transplant documents for additional information:

Clinical Indications

Note: Members must meet the clinical indications as well as the general individual selection criteria for the transplantation to be considered medically necessary.

Medically Necessary:

Kidney transplantation from a deceased or a living donor is considered medically necessary for selected individuals with end stage renal disease. The clinical indications leading to end stage renal disease include, but are not limited to, one of the conditions listed below.

Clinical Indications:

­          Aplasia

­          Hypoplasia

­          Horseshoe Kidney

­          Lead nephropathy

­          Analgesic nephropathy

­          Metabolic Disorders

­          Hyperoxaluria

­          Nephrocalcinosis

­          Gout

­          Amyloidosis

­          Cystinosis

­          Alport's syndrome

­          Polycystic kidney disease

­          Medullary cystic disease

­          Cortical necrosis

­          Hemolytic uremic syndrome

­          Acute and subacute glomerulonephritis

­          Anaphylactoid purpura (Henoch-Schonlein)

­          Chronic pyelonephritis

­          Diabetic nephropathy

­          Chronic glomerulonephritis

­          Hypertensive nephrosclerosis

­          Goodpasture's disease

­          Hypocomplementemic nephritis

­          Steroid-resistant nephrotic syndrome

­          Toxic nephropathy (including nephropathy related to cyclosporine/tacrolimus toxicity)

­          Chronic allograft nephropathy (i.e., chronic rejection)

­          Renal carcinoma

­          Wilms' tumor

­          Tuberous sclerosis

­          Renal artery occlusion

­          Renal vein thrombosis

­          Acquired

­          Congenital

 

­          Scleroderma

­          Polyarteritis (periarteritis nodosa)

­          Multiple Myeloma

­          Lupus Erythematosus

­          Macroglobulinemia

­          Wegner's Disease

­          Etiology unknown (documented chronic renal failure of at least 6-8 weeks duration)

Retransplantation

Repeat transplant due to acute or chronic graft failure is considered medically necessary.

Simultaneous Liver Kidney Transplantation

Kidney transplant as part of a simultaneous liver-kidney (SLK) transplantation is considered medically necessary when criteria for liver transplantation are met and when one of the following are met:

Not Medically Necessary:

Kidney transplantation for conditions other than end stage renal disease is considered not medically necessary.

Kidney transplantation as part of a simultaneous liver kidney (SLK) transplant is considered not medically necessary, if one of the above SLK criteria are not met.

Note: For multi-organ transplant requests, criteria must be met for each organ requested. In those situations, an individual may present with a concurrent medical condition which may be considered an exclusion or a comorbidity that would preclude a successful outcome, but would be treated with the additional organ transplant. Such cases will be reviewed on an individual basis for coverage determination to assess the member's candidacy for transplantation.

 General Individual Selection Criteria 

In addition to having one of the clinical indications above, the member must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.*

Absolute Contraindications- for Transplant Recipients include, but are not limited to, the following:

  1. Metastatic cancer
  2. Ongoing or recurring infections that are not effectively treated
  3. Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery
  4. Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured
  5. Demonstrated patient noncompliance, which places the organ at risk by not adhering to medical recommendations
  6. Potential complications from immunosuppressive medications are unacceptable to the patient.
  7. Acquired immune deficiency syndrome (AIDS) (diagnosis based on Centers for Disease Control and Prevention [CDC] definition of CD4 count, 200cells/mm3) unless the following are noted:
    1. CD4 count greater than 200cells/mm3 for greater than 6 months
    2. HIV-1 RNA undetectable
    3. On stable anti-retroviral therapy greater than 3 months
    4. No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidmycosis, resistant fungal infections, Kaposi's sarcoma or other neoplasm).
    5. Meeting all other criteria for kidney transplantation.

*Steinman, Theodore, et al. Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation. Transplantation. 2001; (71)9:1189-1204.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

CPT 
00868Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient)
50300Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral
50320Donor nephrectomy (including cold preservation); open from living donor
50323Backbench 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
50325Backbench 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
50327Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each
50328Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each
50329Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each
50340Recipient nephrectomy
50360Renal allotransplantation, implantation of graft; without recipient nephrectomy
50365Renal allotransplantation, implantation of graft; with recipient nephrectomy
50547Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
55.69Other kidney transplantation
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Procedure[For dates of service on or after 10/01/2014]
0TY00Z0Transplantation of right kidney, allogeneic, open approach
0TY00Z1Transplantation of right kidney, syngeneic, open approach
0TY10Z0Transplantation of left kidney, allogeneic, open approach
0TY10Z1Transplantation of left kidney, syngeneic, open approach
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
Discussion/General Information

Nearly 26 million Americans have chronic kidney disease (CKD), with 570,000 diagnosed with kidney failure known as end stage renal disease (ESRD) (CDC, 2010). In November of 2012, the Organ Procurement and Transplantation Network reported nearly 94,000 Americans were on the United States wait list for kidney transplantation with approximately 16,000 kidney transplants performed annually (OPTN, 2012).

A kidney transplant involves the surgical removal of a kidney from a deceased or living donor and implanted into a recipient. A donor left kidney is usually transplanted to the right iliac fossa with the renal artery anastomosed end-to-end to the hypogastric artery and the renal vein end-to-side to the common iliac vein. The ureter is implanted into the bladder and (under special conditions) a uretero-ureteral anastomosis or ureteropyelostomy may be performed.

Hepatorenal syndrome is a severe complication of liver cirrhosis or other severe liver disease. Features of hepatorenal syndrome are renal dysfunction caused by abnormalities in the arterial circulation and the vasoactive systems, resulting in renal vasoconstriction and renal insufficiency. There are two types of hepatorenal syndrome. Type I hepatorenal syndrome occurs when renal function is rapidly reduced and has an ominous prognosis which is usually reversed by liver transplantation. Type II hepatorenal syndrome occurs when renal failure does not progress rapidly. It can be quite difficult to distinguish these two conditions in individuals with severe liver disease. Liver transplantation is the recognized treatment for hepatorenal syndrome (Davis, 2005; Marik, 2006).

Concern has been raised since the introduction of the MELD (model for end-stage liver disease) prioritization for liver transplant that some recipients that undergo combined liver and kidney transplantation may have reversible renal failure. To address this issue, the American Society of Transplantation and American Society of Transplant Surgeons met in March 2006 to review post-MELD data on the impact of renal function on liver waitlist and transplant outcomes and the result of simultaneous liver kidney transplantation. This committee issued a consensus statement with regard to simultaneous liver-kidney (SLK) transplantation summarized below (Davis, 2007):

There is a paucity of large prospective randomized controlled trials in the peer reviewed literature to support the use of combined kidney liver transplantation when the duration of renal failure and dialysis is less than six weeks.

Definitions

Allotransplantation: The transfer of cells, tissues, or whole organs from one individual to another within the same species.

Chronic Renal Disease: The permanent loss of kidney function.

End Stage Renal Disease (ESRD): Persistent decline in renal function as documented by falling creatinine clearance in an individual diagnosed with a renal disease whose natural history is progression to renal impairment requiring renal replacement (dialysis or transplant).

Nephropathy: Refers to damage or disease of the kidney.

References

Peer Reviewed Publications:

  1. Bleyer AJ, Donaldson LA, McIntosh M, et al. Relationship between underlying renal disease and renal transplantation outcome. Am J Kidney Dis. 2001; 37:1152-1161.
  2. Cecka JM. The UNOS Scientific Renal Transplant Registry - 2000. Clin Transpl. 2000; 1-18.
  3. Davis CL. Impact of pretransplant renal failure: when is listing for kidney-liver indicated? Liver Transpl. 2005; 11(11 Suppl 2):S35-S44.
  4. Davis C, Feng S, Sung R, et al. Simultaneous liver-kidney transplantation: Evaluation to decision making. Am J Transplant. 2007; 7(7): 1702-1709.
  5. Gjertson DW, Cecka JM. Determinants of long-term survival of pediatric kidney grafts reported to the United Network for Organ Sharing kidney transplant registry. Pedatr Transplant. 2001; 5:5-15.
  6. Gjertson DW, Cecka JM. Living unrelated donor kidney transplantation. Kidney Int. 2000; 58:491-498.
  7. Ishitani M, Isaacs R, Norwood V et al. Predictors of graft survival in pediatric living-related kidney transplant recipients. Transplantation. 2000; 70:288-292.
  8. Marik PE, Wood K, Starzl TE. The course of type 1 hepato-renal syndrome post liver transplantation. Nephrol Dial Transplant. 2006; 21(2):478-482.
  9. Steinman T, Becker BN, Frost AE,  et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001; 71:1189-1204.
  10. Tejani A, Sullivan EK. Do six-antigen-matched cadaver donor kidneys provide better graft survival to children compared with on-haploidentical living-related donor transplants? Pediatr Transplant. 2000; 4:140-145.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Nephrology. Available at: http://www.asn-online.org/home.aspx. Accessed on September 5, 2013.
  2. Centers for Disease Control and Prevention. Chronic kidney disease initiative. Available at: http://www.cdc.gov/diabetes/projects/kidney/index.htm. Accessed on September 5, 2013.
  3. Organ Procurement and Transplantation Network. Available at: http://optn.transplant.hrsa.gov/. Accessed on September 5, 2013.
  4. United Network for Organ Sharing. Available at: http://www.unos.org/. Accessed on September 5, 2013.
Index

Hepatorenal Syndrome
Kidney Transplantation
Renal Allotransplantation
Renal Transplantation
Transplantation, Kidney

History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion, References and Websites.
Reviewed11/08/2012MPTAC review. Updated Discussion, References and Websites.
Reviewed11/17/2011Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References, Coding and Websites.
Revised11/18/2010MPTAC review. Clarified Simultaneous Liver Kidney Transplantation medically necessary clinical indication criteria. Updated References and Websites.
Reviewed11/19/2009MPTAC review.  Place of service removed and references updated.
Reviewed11/20/2008MPTAC review. Clarified not medically necessary statement for kidney transplantation as part of a simultaneous liver kidney transplant. References updated
Revised11/29/2007MPTAC review. Added kidney transplantation as part of a simultaneous liver kidney transplant is considered not medically necessary, if any of the above clinical criteria are not met.
Reviewed08/23/2007MPTAC review. References updated.
New09/14/2006MPTAC review. Document TRANS.00032 converted into a clinical UM guideline.
Reviewed03/23/2006MPTAC review. Definitions added. References updated.
Revised04/28/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.ArchivedTRANS.00007HKidney Transplant
WellPoint Health Networks, Inc.09/23/20047.08.01Kidney Transplantation