Point32 Solid Organ Transplant: Kidney(Eff. beginning 1.1.24) Form

Renal (kidney) transplantation

Renal (kidney) transplantation is a treatment approach in end-stage renal failure. The surgery replaces a diseased kidney with a healthy kidney from a donor (either a live donor or a cadaver donor).

To initiate the prior authorization process, it is necessary to complete and submit the Kidney Transplant Request for Coverage Form.

Clinical Guideline Coverage Criteria

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan Members. MassHealth Medical Necessity Determinations and CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations where available.

For Tufts Health One Care plan Members the following criteria is used:

• MassHealth Medical Necessity Determinations for Organ Transplant Procedures

The Plan may authorize coverage of a kidney transplant for adult and pediatric Members with End Stage Renal Disease (ESRD), of any cause, with a Glomerular Filtration Rate (GFR) < 20 ml/min and/or requiring dialysis, and a satisfactory psychosocial profile, and support systems.

Note: The Plan supports the use of non-race-based calculations of GFR, such as the CKD-EPI Creatinine Equation.

Limitations

The Plan will not authorize the coverage of a kidney transplant in Members with ANY of the following:

1. Active drug, substance abuse, or alcohol abuse within the last 6 months
2. Active or uncontrolled alcohol use disorder or substance use disorder
3. Active Hepatitis B infection
4. Active malignancy
5. Active pulmonary disease including:
   • home oxygen therapy
   • uncontrolled asthma
   • severe Cor Pulmonale
   • severe COPD /Pulmonary Fibrosis/Restrictive lung disease defined as:
   • Best FEV1 < 25% predicted value
   • Exercise desaturation to SaO2 < 90%
   • Greater than 4 episodes of pneumonia in the past 12 months
6. Any unresolved psychosocial concerns or a history of noncompliance with medical management including, but not limited to not attending follow-up appointments, not taking prescription medications, and attending dialysis.
7. Advanced ilio-femoral vascular disease
8. Advanced liver disease due to viral or other etiologies
9. Cardiac ejection fraction < 30%
10. Dementia
11. History of malignancy within past two years, except within the past five years for breast cancer, malignant melanoma, and colorectal cancer (no waiting period for treated basal cell cancer of the skin, in situ bladder cancer, and all non-invasive papillary bladder tumors)
12. Human immunodeficiency virus (HIV) disease unless ALL of the following are met:
    1. Pre-transplant evaluation by an infectious disease specialist with expertise in HIV and transplantation and confirmation of plans for continued follow-up after transplantation with an infectious disease specialist with that expertise.
    2. CD4 count >200 cells/μL during 3 months prior to transplantation
    3. Undetectable HIV-1 ribonucleic acid (RNA)
    4. Stable anti-retroviral therapy for > 3 months
    5. Absence of serious complications associated with or secondary to HIV disease (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections; Kaposi’s sarcoma; or other neoplasm)
13. Nonfunctioning or abnormal lower urinary tract that has not been evaluated and treated by urologist
14. Sickle cell anemia with more than three Sickle Cell Crises requiring hospitalization within the previous 24 months
15. Recurrent infection, uncontrolled or untreated
16. Untreated active coronary artery disease
17. Untreated cerebrovascular disease

Note: Smoking has been strongly correlated to adverse health and surgical outcomes. There is evidence to show that smoking, both by donors and by recipients, has a major impact on outcomes after organ transplantation.

Smoking cessation is strongly recommended for both donors and recipients prior to transplantation

Codes