Medical Policy: 07.03.09 

Original Effective Date: November 2009 

Reviewed: October 2018 

Revised: October 2018 

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

Achievement of insulin dependence with resultant decreased morbidity and increased quality of life is the primary health outcome of pancreas transplantation.  Transplantation of the pancreas is a treatment method for patients with insulin dependent diabetes mellitus. Pancreas transplantation can restore glucose control and is intended to prevent, halt or reverse the secondary complications from diabetes mellitus. While pancreas transplantation is generally not considered a life-saving treatment, in a small subset of patients who experience life-threatening complications from diabetes, pancreas transplantation could be considered life-saving.

 

Pancreas transplantation occurs in several different scenarios such as: 

  • A diabetic patient with renal failure who may receive a simultaneous cadaveric pancreas plus kidney transplant. 
  • A diabetic patient who may receive a cadaveric pancreas transplant after a cadaveric or living-related kidney transplantation. 
  • A nonuremic diabetic patient with severely disabling and potentially life-threatening diabetic problems wo may receive a pancreas transplant alone.

 

Pancreas Transplant Alone (PTA)

The pancreas transplant may involve either the whole pancreas or a pancreas segment. Whole organ transplantation are far more common but a segmental transplant is possible. Segmental transplants are done if a living donor is involved (Organ Procurement and Transplantation Network 2018).

 

Most patients undergoing pancreas transplant alone (PTA) are those with either hypoglycemic unawareness or labile diabetes. However, other exceptional circumstances may exist where nonuremic type I diabetes patients have significant morbidity risks due to secondary complications of diabetes that exceed those of the transplant surgery and subsequent chronic immunosuppression. Because virtually no published evidence addresses outcomes of medical management in this very small group of diabetic patients, is not possible to generalize about which circumstances represent appropriate indications for PTA. Case-by-case consideration of each patient’s clinical situation may be the best option for determining the balance of risks and benefits. The purpose of PTA is to restore glucose control and is intended to prevent, halt or reverse the secondary complications from diabetes such as retinopathy, neuropathy, or end-stage renal disease.

 

Pancreas transplant is not typically used for the treatment of individuals with type II diabetes mellitus. However, according to the International Pancreas Transplant Registry data the proportion of pancreas transplant recipients worldwide who have type II diabetes has increased over time.

 

Pancreas transplantation has been proposed to achieve insulin independence in persons with type II diabetes mellitus. Although the evidence in the peer reviewed medical literature is limited pancreas transplantation is an alternative treatment for insulin dependent individuals with type II diabetes mellitus.

 

For individuals who have insulin dependent diabetes and severe complications who receive pancreas transplant alone (PTA), the evidence includes registry studies. Data from international and national registries have found that graft and patient survival rates after pancreas transplant alone have improved over time (e.g. 3 year survival rate of 95%). The evidence is sufficient to determine that pancreas transplant alone (PTA) results in meaningful improvements in net health outcomes. 

 

Pancreas Transplant after Kidney Transplant (PAK)

Pancreas transplant after kidney (PAK) transplantation permits uremic patients to benefit from a living-related kidney graft, if available, and to benefit from a subsequent pancreas transplant that is likely to improve quality of life compared with a kidney transplant alone. Uremic patients for whom a cadaveric kidney graft is available, but a pancreas graft is not simultaneously available benefit similarly from a later pancreas transplant.

 

The purpose of a pancreas transplant after kidney (PAK) transplant in patients who have insulin-dependent diabetes is to provide a treatment option that is an alternative to or an improvement on existing therapies.  

 

Bazarbachi et. al. (2013) reviewed a single center’s experience with pancreas after kidney (PAK) transplant and simultaneous-kidney pancreas (SPK) transplant. Between 2002 and 2010, 172 pancreas transplant were performed in diabetic patients (123 SPK, 49 PAK). The median length of time between kidney transplant and pancreas transplant in the PAK group was 4.8 years. Graft and patient survival rates were similar for both groups. Death-censored pancreas graft survival rates for SPK and PAK were 94% and 90% at 1 year, 92% and 90% at 3 years, and 85% and 85% at 5 years (p=0.93), all respectively. Patient survival rates (calculated from the time of pancreas transplantation) in the SPK and PAK groups were respectively 98% and 100% after 1 year, 96% and 100% after 3 eyars, and 94% to 100% after 5 years (p=0.09).

 

For individuals who have insulin dependent diabetes who receive a pancreas transplant after a kidney (PAK) transplant, the evidence includes case series and registry studies. Data from national and international registries have found relatively high patient survival rates after pancreas transplant after kidney (PAK), a 3 year survival rate of 93%. A 2013 analysis of data from a single center found similar patient survival and death-censored pancreas graft survival rates after PAK and SPK transplants. The evidence is sufficient to determine the technology results in a meaningful improvement in the net health outcome.

 

Simultaneous Pancreas-Kidney (SPK) Transplant

The kidney is frequently transplanted with the pancreas. Many people suffering from pancreas failure also have renal failure. In most cases a kidney-pancreas transplant is performed from a cadaveric donor. The purpose of simultaneous pancreas-kidney (SPK) transplant in patients who have insulin dependent diabetes with uremia is to provide a treatment option that is an alternative to or an improvement on existing therapies.     

 

Analysis of a U.K. registry data by Barlow et. al. (2017) compared outcomes in patients with type I diabetes and end stage renal disease who had simultaneous pancreas-kidney (SPK) transplants (n=1739) with live donor transplants (n=370). In multivariate analysis, there was no significant association between type of transplant and patient survival (hazard ratio 0.71;95% CI, 0.47 to 1.06; p=0.095). Simultaneous pancreas-kidney recipients with a functioning pancreas graft and significantly better overall survival than those with a living donor kidney transplant (p<0.001).

 

Simultaneous pancreas-kidney (SPK) transplants have been found to reduce mortality in patients with type I diabetes. Van Dellen et. al. (2013) reported on a retrospective analysis of data for 148 SPK patients and a wait-list control group of 120 patients. All patients had type I insulin dependent diabetes. The study also included 33 patients who had pancreas after kidney (PAK) transplant and 11 patients who had pancreas transplant alone (PTA). Overall mortality (mortality at any time point) was 30% (30/120) for the waiting list and 9% (20/193) for transplanted patients; the difference between groups was statistically significant (p<0.001). The 1 year mortality rate was 13% (n=16) for the waiting list and 4% (n=8) for the transplant group (p<0.001).

  

There is some data on outcomes in patients with type II compared with type I diabetes. In 2011, Sampaio et. al. published an analysis of date from the United Network for Organ Sharing (UNOS) database. The investigators compared outcomes in 6141 patients with type I diabetes and 582 patients with type II diabetes who underwent SPK between 2000 and 2007. In adjusted analyses, outcomes were similar between the two groups. After adjusting for other factors such as body weight, dialysis time, and cardiovascular comorbidities, type II diabetes was not associated with an increased risk of pancreas or kidney graft failure or mortality compared with type I diabetes.   

 

For individuals who have insulin-dependent diabetes with uremia who receive simultaneous pancreas-kidney (SPK) transplant, the evidence includes registry studies.  Data from national and international registries have found relatively high patient survival rates with simultaneous pancreas-kidney (SPK) transplants, a 3 year survival rate of 95%. A retrospective analysis found a higher survival rate in patients with type I diabetes who had an SPK transplant than in those on a waiting list. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.  

 

Retransplantation

The last four decades have seen a significant and progressive improvement in outcomes for pancreas transplantation. Improvements in immunosuppression, surgical technique and post-transplant management have all contributed to better graft survival. However, despite refinements in surgical technique, technical failure is defined by the International Pancreas Transplant Registry as graft loss secondary to vascular thrombosis, bleeding, anastomotic leaks or infection/pancreatitis and is responsible for more than 50% of all pancreas grafts lost in the first 6 months following transplantation. Thrombosis accounts for more than one-half of these technical failures, and may be influenced by donor and recipient factors, preservation and ischemic injury, immunological issues and surgical technique.

 

The decision to retransplant the pancreas after an early graft failure is complex. Prior to proceeding with retransplantation, a careful analysis of the factors contributing to the technical failure must be undertaken and reversible risk factors must be addressed. Surgical issues leading to thrombosis such as improper suturing of the vascular anastomosis, poor positioning of the allograft or inadequate hemostasis may be the primary cause of graft thrombosis. However, there may be no obvious surgical cause for graft loss identified. Reconfirming the tissue typing with the original donor and evaluating the patient for hypercoagulable state should be considered prior to attempting retransplantation in order to guide anticoagulation and immunosuppression management for the second graft.

 

Following appropriate evaluation for the causes of graft failure, repeat pancreas transplantation may be considered, although the optimal timing for retransplantation remains somewhat controversial. From a surgical perspective, retransplanting in the early post-pancreatectomy period may be preferable because extensive adhesions have not yet formed, this facilitates placing the new graft in the same anatomic site as the prior transplant. Some previous studies suggest that immediate retransplantation is associated with similar graft and patient survival as primary transplants, others indicate that this approach is associated with higher incidence of post-operative complications and rejection leading to premature loss of the second graft.

 

Several centers have published outcomes after pancreas retransplantation and generally reported comparable graft and patient survival rates after initial transplants and retransplants. For example, Fridell et. al. (2015) reported on 441 initial transplants and 20 late transplants. One year graft survival rates were 92% after initial transplant and 90% after retransplant (p=0.48). Similarly, 1 year patient survival rates were 96% after initial transplant and 95% after retransplant (p=0.53). However, Rudolph et. al. (2015) who assessed the largest number of patients, reported higher graft survival rates but not patient survival rates, after primary transplant. A total of 2145 pancreas transplants were performed, 415 (19%) of which were retransplants. The death-censored graft survival rate at 1 year was 88.2% in initial transplants and 75% in retransplants (p<0.001). Patient survival rates at 1 year were 91% after initial transplant and 88% after retransplant (p=0.06).

 

For individuals who have had a prior pancreas transplant who still meet criteria for a pancreas transplant who receive pancreas retransplantation, the evidence includes national and international data reported form specific transplant centers that have generally reported similar graft and patient survival rates after pancreas retransplantation compared with initial tarnsplantation. Although there are no standard guidelines regarding multiple pancreas transplants, each transplant center has its own guidelines based on experience.  The evidence is sufficient to determine that pancreas retransplantation in patients who still meet criteria for transplant results in meaningful improvement in net health outcomes. 

 

Practice Guidelines and Position Statements

American Diabetes Association

In 2014, the American Diabetes Association issued a position statement regarding type I diabetes through the life span, which included recommendations regarding pancreas transplants.

 

Successful pancreas transplantation has been demonstrated to be efficacious in significantly improving the quality of life of people with diabetes, primarily by eliminating the need for exogenous insulin, frequent daily blood glucose measurements, and many of the dietary restrictions improved by the disorder. Transplantation can also eliminate the acute complications of diabetes.

 

Recommendations

  • Consider solid organ pancreas transplantation simultaneously with kidney transplantation in patients with type I diabetes who have an indication for kidney transplantation and are poorly controlled with large glycemic excursions.
  • Consider solid organ pancreas transplantation after kidney transplantation in adult patients with type I diabetes who have already received a kidney transplant.
  • Judiciously consider solid organ pancreas transplantation alone in adults with type I diabetes, unstable glucose control, hypoglycemia unawareness, and an increased risk of diabetes-related mortality, who have attempted all of the more traditional approaches to glycemic control and have remained unsuccessful, yet are judged responsible enough to manage the anti-rejection medication regimen, risk, and follow-up required with an organ transplant.  

 

Organ Procurement and Transplantation Network

In 2018 the following is the allocation policies of the Organ Procurement and Transplantation Network for the Allocation of Pancreas and Kidney-Pancreas:

 

Pancreas Registration

Each candidate registered on the pancreas waiting list must meet one of the following requirements:

  • Be diagnosed with diabetes
  • Have pancreatic exocrine insufficiency
  • Require the procurement of transplantation of a pancreas as part of a multiple organ transplant for technical reasons 

 

Combined Kidney-Pancreas Registration

Each candidate registered on the kidney-pancreas waiting list must be diagnosed with diabetes or have pancreatic exocrine insufficiency with renal insufficiency.

 

Prior Approval:

 

Prior approval is required.

 

Policy:

See related medical policy 07.03.01 Pancreatic Islet Cell Transplant 

 

Pancreas Transplant Alone (PTA)

Pancreas transplant alone (PTA) may be considered medically necessary in patients who have insulin-dependent diabetes mellitus with severe disabling and life threatening hypoblycemic unawareness due to labile diabetes despite optimal medical management (also, see policy guidelines below).

 

Pancreas-after-Kidney (PAK) Transplant

Pancreas transplant after a prior kidney (PAK) transplant may be considered medically necessary in patients with insulin-dependent diabetes.

 

Simultaneous Pancreas-Kidney (SPK) Transplant

Simultaneous pancreas-kidney (SPK) transplant may be considered medically necessary in insulin-dependent diabetics with impending or established renal failure.

 

Pancreas Transplant Alone (PTA)/Pancreas Transplant after Prior Kidney Transplant (PAK)/Simultaneous Pancreas-Kidney Tranplant (SPK)

Pancreas transplant alone (PTA), pancreas transplant after prior kidney transplant (PAK), or simultaneous pancreas-kidney transplant (SPK) performed for any other conditions not listed above will be considered not medically necessary.

 

Retransplantation

Pancreas transplant alone (PTA), pancreas after kidney (PAK) or simultaneous pancreas-kidney (SPK) retransplantation after a failure of the primary graft may be considered medically necessary provided the individual meets the transplant criteria above.

 

Policy Guidelines

Pancreas Specific Criteria

Candidates for pancreas transplant alone (PTA) should additionally meet 1 of the following severity of illness criteria:

  • Documentation of severe hypoglycemia awareness as evidenced by chart notes or emergency department visits; or
  • Documentation of potentially life-threatening labile diabetes, as evidenced by chart notes or hospitalization for diabetic ketoacidosis. 

In addition, most pancreas transplant patients will have type I diabetes mellitus. Those transplant candidates with type II diabetes mellitus, in addition to being insulin dependent, should also not be obese (body mass index (BMI) should be 32 kg/m2 or less).

 

Retransplantation

Although there are no standard guidelines regarding multiple pancreas transplants (retransplantations), the following information may aid in case review:

  • If there is early graft loss resulting from technical factors (e.g. venous thrombosis), a retransplant may generally be performed without substantial additional risk.
  • Long-term graft losses may result from chronic rejection, which is associated with increased risk of infection following long-term immunosuppression, and sensitization, which increases the difficulty of finding a negative cross-match. Some transplant centers may wait to allow reconstitution of the immune system before initiating retransplant with an augmented immunosuppression protocol.  

 

Potential contraindications to pancreas transplant are subject to the judgement of the transplant center including the following:

  • Known current malignancy, including metastatic cancer
  • Recent malignancy with high risk of recurrence
  • Untreated systemic infection making immunosuppression unsafe, including chronic infection
  • Other irreversible end-stage disease not attributed to kidney disease
  • History of cancer with moderate risk of recurrence
  • Systemic disease that could be exacerbated by immunosuppression
  • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

 

Procedure Codes and Billing Guidelines:

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
  • 48554 Transplantation of pancreatic allograft
  • S2065 Simultaneous pancreas kidney transplantation

 

Selected References:

  • Aguera ML, Navarro MD, Perez-Calderon R et al. Simultaneous pancreas-kidney transplant: a single-center long-term outcome. J Nephrol. 2007 Mar-Apr; 20(2):173-6.
  • Bunnapradist S, Cho YW, Cecka JM et al Kidney allograft and patient survival in type 1 diabetic recipients of cadaveric kidney alone versus simultaneous pancreas/kidney transplants: a multivariate analysis of the UNOS database. J Am Soc Nephrol. 2003 Jan;14(1):208-13.
  • Humar A, Ramcharan T, Kandaswamy R et al. Pancreas after kidney transplants. Am J Surg. 2001 Aug;182(2):155-61.
  • Humar A, Kandaswamy R, Drangstveit MB et al. Surgical risks and outcome of pancreas retransplants. Surgery. 2000 Jun;127(6):634-40.
  • Johnson SR, Cherikh WS, Kauffman HM et al. Retransplantation after post-transplant lymphoproliferative disorders: an OPTN/UNOS database analysis. Am J Transplant. 2006 Nov;6(11):2743-9.
  • Kizilel S, Garfinkel M, Opara E. The bioartificial pancreas: progress and challenges. Diabetes Technol Ther. 2005 Dec;7(6):968-85.
  • Lipshutz GS, Wilkinson AH. Pancreas-kidney and pancreas transplantation for the treatment of diabetes mellitus. Endocrinol Metab Clin North Am. 2007 Dec;36(4):1015-38.
  • Sutherland DE, Gruessner AC. Long-term results after pancreas transplantation. Transplant Proc 2007;39(7):2323-5.
  • Scalea JR, Burler CC, Munivenkatappa RB et al. Pancreas transplant alone as an independent risk factor for the development of renal failure: a retrospective study. Transplantation 2008;86(12):1789-94.
  • Hirshberg B. The cardinal features of recurrent autoimmunity in simultaneous pancreas-kidney transplant recipients. Curr Diab Rep 2010; 10(5):321-2.
  • Fridell JA, Mangus RS, Hollinger EF et al. The case for pancreas after kidney transplantation. Clin Transplant 2009; 23(4):447-53.
  • Kleinclauss F, Fauda M, Sutherland DE et al. Pancreas after living donor kidney transplants in diabetic patients: impact on long-term kidney graft function. Clin Transplant 2009; 23(4):437-46.
  • Schenker P, Vonend O, Kruger B et al. Long-term results of pancreas transplantation in patients older than 50 years. Transpl Int. 2011 Feb; 24(2):136-42. doi: 10.1111/j.1432-2277.2010.01172.x. Epub 2010 Oct 13.
  • Afaneh C, Rich BS, Aull MJ et al. Pancreas transplantation: does age increase morbidity? J transplant. 2011; 2011:596801. Epub 2011 Jun 4.
  • Gruessner AC. 2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud. 2011 Spring; 8(1):6-16. Epub 2011 May 10.
  • Sampaio MS, Kuo HT, Bunnapradist S. Outcomes of simultaneous pancreas-kidney transplantation in type 2 diabetic recipients. Clin J AM Soc Nephrol. 2011 May;6(5):1198-206. Epub 2011 Mar 24.
  • UpToDate. Pancreas and Islet Transplantation in Diabetes Mellitus. R. Paul Robertson, M.D.. Topic last updated April 30, 2013.
  • United Network for Organ Sharing (UNOS): Pancreas Allocation Policy. September 1, 2013.
  • CMS. National Coverage Determination for Pancreas Transplants (260.3).
  • UpToDate. Patient Selection for an Immunologic Issues Relating to Kidney-Pancreas Transplantation in Diabetes Mellitus. Topic last updated February 3, 2016. 
  • Medscape. Pancreas Transplantation Updated June 12, 2013.
  • Medscape. Kidney-Pancreas Transplantation Updated September 18, 2013. 
  • American Diabetes Association Pancreas Transplantation.  Diabetes Care 2004 Jan;27 (suppl 1): s105-s105 
  • National Kidney Foundation Pancreas Transplant.
  • Organ Procurement and Transplant Network (OPTN). Allocation of Pancreas, Kidney-Pancreas and Islets. October 2016. 
  • Gruessner Angelika C, 2011 Update on Pancreas Transplantation: Comprehensive Trend Analysis of 25,000 Cases Followed up over the Course of Twenty-Four years at the International Pancreas Transplant Registry (IPTR). Journal of the Society of Biomedical Diabetes Research, April 2011. Published online May 10, 2011. Doi:10.1900/RDS.2011.8.6
  • E.F. Hollinger, J.A. Powelson, et. al. Immediate Retransplantation for Pancreas Allograft Thrombosis, American Journal of Transplantation 2009; 9:740-745.
  • National Guideline Clearinghouse. Clinical Practice Guideline for Diabetes Mellitus Type 1. May 2012.
  • National Institute of Health (NIH). Microencapsulation of Pancreatic Islets for use in Bioartificial Pancreas.
  • Sampaio MS, Kuo HT, Bunnapradist S. Outcomes of simultaneous pancreas-kidney transplantation in type 2 diabetic patients. Clin J Am Soc Nephrol 2011;6(5):1198-1206
  • Gruessner AC, Sutherland DE, Gruessner RW. Long-term outcome after pancreas transplantation. Curr Opin Organ Transplant 2012 Feb;17(1):100-5. PMID 22186094
  • Blumberg E.A., Rogers C.C., The American Society of Transplantation Infectious Diseases Guidelines 3rd Edition, Human Immunodeficiency Virus in Solid Organ Transplantation. American Journal of Transplantation Volume 13,Issue s4 March 2013 pages 169-178
  • Buron F, Thaunat O, Demuylder-Mischler S, et.al. Pancreas retransplantation: a second chance for diabetic patients? Transplantation 2013 Jan 27;95(2):347-52. PMID 23222920
  • Van Dellen D, Worthington J, Mitu-Pretorian OM, et. al. Mortality in diabetes: pancreas transplantation is associated with significant survival benefit. Nephrol Dial Transplant 2013 May;28(5):1315-22. PMID 23512107
  • Bazerbachi F, Selzner M, Marquez MA, et. al. Pancreas-after-kidney versus synchronous pancreas-kidney- transplantation: comparison of intermediate term results. Transplantation 2013 Feb 15;95(3):489-94. PMID 23183776
  • Seal J, Selzner M, Laurence J, et. al. Outcomes of pancreas retransplantation after simultaneous kidney-pancreas transplantation are comparable to pancreas after kidney transplantation alone. Transplantation 2015 Mar;99(3):623-8. PMID 25148379
  • Siskind E, Maloney C, Akerman M, et.al. An analysis of pancreas transplantation outcomes based on age groupings – an update of the UNOS database. Clin Transplant 2014 Sep;28(9):990-4. PMID 24954160
  • UpToDate. Pancreas and Islet Transplantation in Diabetes Mellitus. R Paul Robertson M.D., Topic last updated March 7, 2016.
  • Gruessner AC, Gruessner RW. Pancreas Transplantation of US and Non-US Cases from 2005 to 2014 as Reported to the United Network of Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud. Spring 2016;13(1)35-58. PMID 26982345
  • Barlow AD, Saeb-Parsy K, Watson CJE. An analysis of the survival outcomes of simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type 1 diabetes: a UK transplant registry study. Transpl Int. Mar 20 2017. PMID 28319322
  • Fridell JA, Mangus RS, Chen JM, et. al. Late pancreas retransplantation. Clin Transplant. Jan 2015;29(1):1-8. PMID 25284041
  • Rudolph EN, Finger EB, Chandolias N, et. al. Outcomes of pancreas retransplantation. Transplantation Feb 2015;99(2):367-374. PMID 25594555
  • Shah AP, Mangus RS, Powelson JA, et. al. Impact of recipient age on whole organ pancreas transplantation. Clin Transplant. Jan-Feb 2013;27(1):E49-55. PMID 23228216
  • Chiang J, Kirkman MS, Laffel L, et. al. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014;37:2034-2054
  • Organ Procurement and Transplantation Network (OPTN). Organ Procurement an Transplantation Network Policies Allocation of Pancreas, Kidney-Pancreas and Islets. 
  • Barlow AD, Saeb-Parsy K, Watson CJE. An analysis of the survival outcomes fo simultaneous pancreas and kidney transplantation compared to live donor kidney transplantation in patients with type I diabetes: a UK transplant registry study. Transpl Int. Sept 2017;30(9):884-892. PMID 28319322

 

Policy History:

  • October 2018 - Annual Review, Policy Revised
  • October 2017 - Annual Review, Policy Renewed
  • October 2016 - Annual Review, Policy Revised
  • November 2015 - Annual Review, Policy Revised
  • December 2014 - Annual Review, Policy Revised
  • January 2014 - Annual Review, Policy Renewed
  • March 2013 - Annual Review, Policy Renewed
  • March 2012 - Annual Review, Policy Renewed
  • April 2011 - Annual Review, Policy Renewed

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.