CMS Pub. 100-04, ch. 3, § 90.5.1

A. - General

Pancreas transplantation is performed to induce an insulin-independent, euglycemic state in

diabetic patients. The procedure is generally limited to those patients with severe secondary

complications of diabetes, including kidney failure. However, pancreas transplantation is

sometimes performed on patients with labile diabetes and hypoglycemic unawareness.

Medicare has had a long-standing policy of not covering pancreas transplantation, as the

safety and effectiveness of the procedure had not been demonstrated. The Office of Health

Technology Assessment performed an assessment of pancreas-kidney transplantation in

1994. It found reasonable graft survival outcomes for patients receiving either simultaneous

pancreas-kidney transplantation or pancreas-after-kidney transplantation.

B. - Nationally Covered Indications

CMS determines that whole organ pancreas transplantation will be nationally covered by

Medicare when performed simultaneous with or after a kidney transplant. If the pancreas

transplant occurs after the kidney transplant, immunosuppressive therapy will begin with the

date of discharge from the inpatient stay for the pancreas transplant.

C. - Billing and Claims Processing

Contractors shall pay for Pancreas Transplantation Alone (PA) effective for services on or

after April 26, 2006 when performed in those facilities that are Medicare-approved for

kidney transplantation. Approved facilities are located at the following address:

https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf

The shared system shall Return To Provider (RTP) claims for PA services that were

performed in an unapproved facility. Payment will be made for a PA service performed in

an approved facility, and which meets the coverage guidelines mentioned above for

beneficiaries with type I diabetes.

All-Inclusive List of Covered Diagnosis Codes for PA if ICD-9-CM is applicable

(NOTE: “X” = 1 and 3 only)

ICD-9-CM

code

Description

250.0X Diabetes mellitus without mention of complication, type I (insulin

dependent) (IDDM) (juvenile), not stated as uncontrolled.

250.1X Diabetes with ketoacidosis

250.2X Diabetes with hyperosmolarity

250.3X Diabetes with coma

250.4X Diabetes with renal manifestations

250.5X Diabetes with ophthalmic manifestations

250.6X Diabetes with neurological manifestations

250.7X Diabetes with peripheral circulatory disorders

250.8X Diabetes with other specified manifestations

250.9X Diabetes with unspecified complication

If ICD-10-CM is applicable, , the provider uses the following range of ICD-10-CM

codes:

E10.10 – E10.9.

Procedure Codes

If ICD-9 CM is applicable

52.80 - Transplant of pancreas

52.82 - Homotransplant of pancreas

If ICD-10 is applicable, the provider uses the following ICD-10-PCS codes:

0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach

0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach

Contractors who receive claims for PA that are not billed using the covered

diagnosis/procedure codes listed above shall Return To Provider (RTP) such claims. The

MCE edits to ensure that the transplant is covered based on the diagnosis. The MCE also

considers ICD-9-CM codes 52.80 and 52.82 and ICD-10-PCS codes 0FYG0Z0 and

0FYG0Z1 as limited coverage dependent upon whether the facility is approved to perform

the transplant and is certified and Return To Provider (RTP) as appropriate.

D. - Charges for Pancreas Alone Acquisition Services

A separate organ acquisition cost center has been established for pancreas transplantation.

The Medicare cost report will include a separate line to account for pancreas transplantation

costs. The 42 CFR 412.2(e)(4) was changed to include PA in the list of organ acquisition

costs that are paid on a reasonable cost basis.

Acquisition costs for PA transplantation are billed in Revenue Code 081X. The contractor

removes acquisition charges prior to sending the claims to Pricer so such charges are not

included in the outlier calculation.