UM Guidelines
Renal Transplant

Inpatient and Surgical Care (ISC) ORG: S-1015

BCBST modification effective December 10, 2013*

Deleted:
   
 

There were no deletions.


Added to: Clinical Indications
   
  • A supportive family / social milieu
  • No history of previous malignancies or be cancer-free for five years
  • No untreated and unreversed serious infections
  • No surgical contraindications such as urologic or vascular problems (e.g., advanced aortoiliac vascular disease)
  • No active drug and/or alcohol use (must be alcohol and/or drug-free for six months as documented by randomized drug screen)
  • Documentation related to human immunodeficiency virus (HIV) including 1 or more of the following:
    • The individual is negative for human immunodeficiency virus (HIV)
    • The individual is positive for human immunodeficiency virus (HIV), but has no advancing / symptomatic HIV disease as indicated by ALL the following:
      • CD4 count >200 cells per cubic millimeter for >6 months
      • HIV-1 RNA undetectable
      • Stable anti-retroviral therapy >3 months
      • Absence of complications from AIDS (e.g. opportunistic infections, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections Kaposi’s sarcoma or other neoplasm)

Sources

BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2013). Kidney Transplant (7.03.01) Retrieved August 27, 2013 from BlueWeb. (14 articles and/or guidelines reviewed)

BlueCross BlueShield of Tennessee network physicians. September - December 2013.