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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut TRANS.00041 Histological Analysis using Microarray Gene Expression Profiling for Kidney Allograft Injury or Rejection Form

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses histological analysis using microarray gene expression profiling (e.g., Molecular Microscope® Diagnostic System [MMDx®, Kashi Clinical Laboratories, Portland, OR]) as a complement to conventional biopsy processing when assessing for allograft injury or rejection in kidney transplant recipients. This document does not address the use of organ biopsy or non-invasive methods to monitor for or detect kidney allograft injury or rejection.

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

  • CG-TRANS-02 Kidney Transplantation
  • LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
  • GENE.00058 TruGraf Blood Gene Expression Test for Transplant Monitoring

Position Statement

Investigational and Not Medically Necessary:

Histological analysis using microarray gene expression profiling is considered investigational and not medically necessary for detection of allograft injury or rejection in kidney transplant recipients and for all indications.