United HealthcareCommercial Clinical Policy

Transplant Review Guidelines: Solid Organ Transplantation Form

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Kidney Transplant

Indications

(279354) Does the patient have end-stage renal disease (ESRD) or other kidney conditions leading to a requirement for transplant? 

Contraindications

(279355) Are there any organ-specific contraindications present for the patient that would prevent kidney transplantation? 

Liver Transplant

Indications

(279356) Does the patient have liver failure or other liver conditions leading to a requirement for transplant? 

Contraindications

(279357) Are there any organ-specific contraindications present for the patient that would prevent liver transplantation? 

Pancreas and Kidney/Pancreas Transplant

Indications

(279358) Does the patient require a pancreas or combined kidney/pancreas transplant due to diabetes or another pancreas-related condition? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

12/07/2023

Last Reviewed

NA

Original Document

  Reference



5 Kidney including kidney/liver, kidney/heart, and kidney/lung

  • General Information: 7
  • Indications: 7
  • Organ-specific contraindications: 8
  • Considerations for substance use disorder: 8
  • Special Considerations: 9

Liver

  • General Information: 12
  • Indications: 13
  • Organ-specific contraindications: 14
  • Considerations for substance use disorder: 14
  • Special considerations: 15

Pancreas and kidney/pancreas

  • General information: 19
  • Indications: 20
  • Organ-specific contraindications: 20
  • Considerations for substance use disorder: 21
  • Special considerations: 21

Donislecel (Lantidra)

  • General information: 24
  • Indications: 24
  • Special considerations: 25

Intestine including liver/intestine and multivisceral

  • General information: 26
  • Indications: 26
  • Organ-specific contraindications: 27
  • Considerations for substance use disorder: 27
  • Special considerations: 28

Heart

  • General information: 30
  • Indications: 30
  • Organ-specific contraindications: 32
  • Considerations for substance use disorder: 32
  • Special considerations: 32

Lung

  • General information: 36
  • Indications: 36
  • Organ-specific contraindications: 38
  • Considerations for substance use disorder: 38
  • Special considerations: 39

Heart/Lung

  • General information: 41
  • Indications: 41
  • Organ-specific contraindications: 41
  • Considerations for substance use disorder: 41
  • Special considerations: 41

Reference

42

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