Pancreas Transplants Alone (PA)

90.5.1 - Pancreas Transplants Alone (PA) (Rev.: 13757; Issued: 04-30-26; Effective: 04-01-26; Implementation: 04-06-26) 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.