Anthem Blue Cross Connecticut TRANS.00010 Autologous and Allogeneic Pancreatic Islet Cell Transplantation Form

This document addresses autologous and allogeneic pancreatic islet cell transplantation. Islet cell transplantation involves the collection and infusion of isolated pancreatic islet cells into the portal vein of the liver. The goals of islet cell transplantation are to preserve endocrine functionc, glycemic control and to improve quality of life.

Note: For information on whole pancreas organ transplantation, please see:

• TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation

Position Statement

Medically Necessary:

Autologous pancreatic islet cell transplantation is considered medically necessary as an adjunct to a total or near total pancreatectomy for individuals with chronic pancreatitis.

Investigational and Not Medically Necessary:

Autologous pancreatic islet cell transplantation is considered investigational and not medically necessary when the above criteria are not met and for all other indications.

Allogeneic pancreatic islet cell transplantation is considered investigational and not medically necessary for all indications.

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 would be considered an exclusion or a comorbidity that would preclude a successful outcome, but would be treated with the other organ transplant. Such cases will be reviewed on an individual basis for coverage determination to assess the member's candidacy for transplantation.