Sunflower Health Plan Pediatric Kidney Transplant (PDF) Form

Kidney transplantation is the preferred treatment option for pediatric patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD).1-4 This policy establishes the medical necessity requirements for pediatric kidney transplants. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that pediatric kidney transplantation for pediatric members/enrollees (age < 18) is medically necessary when all of the following conditions are met: A. Advanced renal disease including one of the following: 1. End stage renal disease (stage 5) with glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2; 2. Chronic kidney disease (CKD) (stage 4) with GFR ≤ 30 mL/min/1.73m2 or GFR > 30 mL/min/1.73m2 with rapid progression toward end-stage renal disease (ESRD), and all of the following: a. Irreversible renal disease; b. Symptoms are refractory to medical management (eg, uremic neuropathy, pericarditis, mental status changes, severe fatigue, pruritus, nausea, muscle cramps, unintentional weight loss). ** Note: Patients with a GFR above 30 mL/min/1.732 who are rapidly progressing toward ESRD should be referred for kidney transplant evaluation. B. Does not have any of the following contraindications: 1. Active infection that is not properly treated, including but not limited to, acute hepatitis C virus infection with elevated International Normalized Ratio (INR) or transaminitis; 2. HIV infection with detectable viral load; 3. Malignancy with high risk of recurrence or death related to cancer; 4. Stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within the past 6 months or transient ischemic attack within the past 3 months; 5. Severe, life threatening extrahepatic multi-organ mitochondrial disease; 6. Septic shock; 7. Progressive cognitive impairment; 8. Other severe uncontrolled medical condition expected to limit survival after transplant; 9. Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support; 10. Absence of an adequate or reliable social support system; Page 1 of 5 CLINICAL POLICY Pediatric Kidney Transplant 11. Active substance use or dependence including current tobacco use, vaping, marijuana smoking, or IV drug use without convincing evidence of risk reduction behaviors, such as meaningful and/or long-term participation in therapy for substance abuse and/or dependence. Serial blood and urine testing may be used to verify abstinence from substances that are of concern; 12. Acute pancreatitis within the last 3 months; 13. Decompensated cirrhosis unless candidate for combined liver-kidney transplant; 14. Active gastrointestinal disease including symptomatic peptic ulcers, diverticulitis, inflammatory bowel disease, or gallbladder disease; 15. Surgical contraindications (eg, urologic or vascular problems); 16. Elevated levels of circulating antiglomerular basement membrane antibodies; 17. Severe irreversible multisystem organ system failure not correctable by organ transplant. Background Kidney transplantation is an effective treatment option for advanced chronic kidney disease (CKD) and end stage renal disease (ESRD) as it improves quality of life and increases patient survival in comparison to dialysis.1-4 Decline in growth rate is a common complication in children with CKD, and poor growth can indicate disease severity and be associated with substantial morbidity and mortality.3 Kidney transplantation can prevent and improve growth failure, particularly in young children under six years of age.2-3 Determining candidates for kidney transplantation requires a multidisciplinary care team approach and careful consideration of the individual’s unique situation. In the pediatric patient population, preemptive kidney transplantation proves to be the most successful treatment option for ESRD, due to having the highest graft survival rates and the lowest mortality rates. Preemptive or primary transplantation is when kidney transplantation is the first treatment for ESRD and typically involves a transplant from a living donor related to the patient. Preemptive kidney transplantation is also an optimal treatment option because it allows patients to receive treatment before side effects and potential medical complications arise from dialysis.2 According to the 2020 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines regarding the evaluation and management of kidney transplant candidates, it is recommended that the cause of ESRD be determined, when possible, in order to be better informed of risks and management for patients following kidney transplantation.5 According to the North American Pediatric Renal Trials and Collaborate Studies (NAPRTCS) registry from 1987 to 2017, 30% of pediatric kidney transplant recipients have primary diagnoses that involve congenital anomalies of the kidney and urinary tract, such as renal dysplasia, renal aplasia, renal, hypoplasia, and obstructive uropathy.2 Additional underlying etiologies for pediatric kidney transplant recipients include hereditary kidney disease, reflux nephropathy, pyelonephritis, interstitial nephritis, hemolytic uremic syndrome, and acquired glomerular disease, such as focal segmental glomerulosclerosis and lupus nephritis.2,4 Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted Page 2 of 5 CLINICAL POLICY Pediatric Kidney Transplant 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT® Codes 50300 50320 50323 50325 50327 50328 50329 50360 50365 50547 HCPCS Codes S2152 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral Donor nephrectomy (including cold preservation); open, from living donor Backbench 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 Backbench 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 Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each Renal allotransplantation, implantation of graft; without recipient nephrectomy Renal allotransplantation, implantation of graft; with recipient nephrectomy Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition Reviews, Revisions, and Approvals Policy developed. Review Date 09/22 Approval Date 09/22 Page 3 of 5