Medical Policy
Effective Date:01/01/2007 Title:Islet Cell Transplantation
Revision Date:10/01/2015 Document:BI180:00
CPT Code(s):48160, G0341-G0343, S2102
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

QualChoice maintains a national network of Centers of Excellence for members who require transplantation.

 

Transplants and transplant related services are covered only when performed at a transplant center previously approved by QualChoice.

1)    Islet cell transplantation is the infusion of pancreatic islet cells into the liver circulation in an effort to restore or preserve insulin production in persons who have lost or are at risk to lose that function.

2)    Islet cell transplantation from a donor is not covered.

3)    Islet cell auto-transplantation (auto-transplantation involves transplanting cells back into the same person from whom they were taken) requires pre-authorization.
Medical Statement

Islet cell auto-transplantation is considered medically necessary in members who are undergoing total or near total resection of the pancreas for severe refractory chronic pancreatitis (K86.0-K86.1).

 

 

Codes Used In This BI:

48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells
G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion
G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion
G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion
S2102 Islet cell transplant, allogeneic
 
Limits

Allogenic islet cell transplantation is considered experimental/ investigational in the treatment of Diabetes mellitus as there is insufficient documentation in the peer reviewed published medical literature of its effectiveness and safety Hayes C&D.
Reference

1)    Shapiro AM, Ryan EA, Lakey JR. Pancreatic islet transplantation in the treatment of diabetes mellitus. Best Pract Res Clin Endocrinol Metab. 2001;15(2):241-264.

2)    White SA, Kimber R, Veitch PS, et al. Surgical treatment of diabetes mellitus by islet cell and pancreas transplantation. Postgrad Med J. 2001;77(908):383-387.

3)    Robertson RP, Davis C, Larsen J, et al. Pancreas and islet transplantation for patients with diabetes. Diabetes Care. 2003;26 Suppl:S120.

4)    Guo B, Harstall C, Corabian P. Islet cell transplantation for the treatment of non-uremic type 1 diabetic patients with severe hypoglycemia. Health Technology Assessment. HTA 31. Edmonton, AB: Alberta Heritage Foundation for Medical Research (AHFMR); April 2003.

5)    Hayes, Islet cell transplantation for the treatment of Type 1 diabetes; August 2004

6)    Hering BJ, Kandaswamy R, Ansite JD, et al. Single-donor, marginal-dose islet transplantation in patients with type 1 diabetes. JAMA. 2005;293(7):830-835.

7)    Korsgren O, Nilsson B, Berne C, et al. Current status of clinical islet transplantation. Transplantation. 2005;79(10):1289-1293.

8)    Guo B, Harstall C, Corabian P. Islet cell transplantation for the treatment of non-uremic type 1 diabetic patients with severe hypoglycemia. Edmonton, AB: Alberta Heritage Foundation for Medical Research (AHFMR); 2003.

9)    National Institute for Clinical Excellence (NICE). Pancreatic islet cell transplantation. Interventional Procedure Guidance 13. London, UK: NICE; October 2003.

10) Rodriguez Rilo HL, Ahmad SA, D`Alessio D, et al. Total pancreatectomy and autologous islet cell transplantation as a means to treat severe chronic pancreatitis. J Gastrointest Surg. 2003;7;978-989.

11) Jie T, Hering BJ, Ansite JD, et al. Pancreatectomy and auto-islet transplant in patients with chronic pancreatitis [abstract]. Surgical Forum, Alimentary Tract Category. #2005-466. American College of Surgeons 91st Annual Clinical Congress, San Francisco, CA, October 16-20, 2005.

12) Clayton HA, Davies JE, Pollard CA, et al. Pancreatectomy with islet auto transplantation for the treatment of severe chronic pancreatitis: The first 40 patients at the Leicester General Hospital. Transplantation. 2003;76(1):92-98.

13) Ryan EA, Bigam D, Shapiro AM. Current indications for pancreas or islet transplant. Diabetes Obes Metab. 2006;8(1):1-7.

14) Balamurugan AN, Bottino R, Giannoukakis N, Smetanka C. Prospective and challenges of islet transplantation for the therapy of autoimmune diabetes. Pancreas. 2006;32(3):231-243.

15) American Diabetes Association; Islet cell transplant program for type 1 diabetes successful across international centers at: http://www.diabetes.org/for-media/2004-press-releases/edmonton.jsp
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.