Anthem Blue Cross Connecticut CG-TRANS-02 Kidney Transplantation Form

This document addresses kidney transplantation, involving 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:

• TRANS.00008 Liver Transplantation
• TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation

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.

*Note: See Definition section for further information on end stage renal disease.

Clinical Indications:

• Congenital Disorders
  • Aplasia
  • Hypoplasia
  • Horseshoe Kidney

• Toxic Nephropathies
  • Lead nephropathy
  • Analgesic nephropathy
  • Metabolic Disorders
  • Hyperoxaluria
  • Nephrocalcinosis
  • Gout
  • Amyloidosis
  • Cystinosis

• Hereditary Nephropathies
  • Alport's syndrome
  • Polycystic kidney disease
  • Medullary cystic disease

• Irreversible Acute Renal Failure
  • Cortical necrosis
  • Hemolytic uremic syndrome
  • Acute and subacute glomerulonephritis
  • Anaphylactoid purpura (Henoch-Schonlein)

• Irreversible Chronic Renal Failure
  • 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 (that is, chronic rejection)

• Tumors Requiring Nephrectomy
  • Renal carcinoma
  • Wilms’ tumor
  • Tuberous sclerosis

• Renal Vascular Diseases
  • Renal artery occlusion
  • Renal vein thrombosis

• Obstructive Uropathy
  • Acquired
  • Congenital

• Trauma requiring nephrectomy

• Other Indications
  • 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:

• The individual has acute renal failure secondary to either hepatorenal syndrome or acute kidney injury; either of which have required at least 6 weeks of dialysis therapy; or
• The individual has chronic kidney disease with a measured creatinine clearance of less than or equal to 30cc/min; or
• The individual has prolonged acute kidney failure or kidney failure of unknown cause and a renal biopsy showing fixed renal damage.

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 is 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 (for example, opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, 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.