Member has chronic renal failure with anticipated deterioration to end stage renal disease, where member is seeking precertification for cadaveric kidney transplantation Footnote1* or.Member is already on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) or.Attending physician determines that there is no prohibitive hepatic risk and.Attending physician determines that there is no prohibitive pulmonary risk and.Attending physician determines that there is no prohibitive cardiovascular risk and.No other complications from AIDS, such as opportunistic infection (e.g., aspergillus, coccidiomycosis, resistant fungal infections, tuberculosis), Kaposi's sarcoma or other neoplasms and.On stable anti-viral therapy for more than 3 months and.HIV-1 RNA (viral load) undetectable and.CD4 count greater than 200 cells/mm 3 for more than 6 months and.Absence of symptomatic HIV infection, as defined by all of the following:.Women should have a negative Pap smear within the past 3 years and mammography, where indicated, within the past 2 years and Absence of malignancy (except for non-melanomatous skin cancers or low-grade prostate cancer) or the malignancy has had curative therapy (e.g., surgical resection of non-invasive squamous cell or basal cell skin cancer) or the estimated risk of recurrence of the malignancy is less than 10% within the next 2 years.įor example, renal cell carcinoma treated by nephrectomy with no evidence of metastatic disease 2 years after the nephrectomy, prostate cancer with negative prostate-specific antigen levels after treatment, surgically treated colon cancer, thyroid cancer with normal thyroglobulin levels after therapy, and others.Member meets transplanting institution's protocol eligibility criteria regarding age and.While the transplant evaluation of persons with kidney disease may be indicated, the medical necessity for transplantation itself depends on the results of the evaluation and Note: Frequently requests for evaluation for transplantation are confused with requests for the transplantation itself. Member has completed an evaluation and been accepted by the kidney transplant committee at the kidney transplantation center.In the absence of an institution’s selection criteria, Aetna considers kidney transplantation medically necessary when all of the following criteria below are met: This Clinical Policy Bulletin addresses kidney transplantation.Īetna considers kidney transplantation medically necessary for members who meet the transplanting institution’s selection criteria. Number: 0493 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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