Aetna · Clinical coverage policy

Aetna Kidney Transplantation coverage criteria

Aetna CPB 0493 covers kidney transplantation as medically necessary when the member meets the transplant center's selection criteria, or in their absence, all of Aetna's listed criteria (committee acceptance, age, absence of disqualifying malignancy/infection, controlled HIV if present, acceptable cardiac/pulmonary/hepatic risk, and a severity-of-disease pathway: on dialysis, OR chronic renal failure progressing to ESRD for a cadaveric transplant, OR ESRD with creatinine clearance below 20 ml/min or uremia symptoms for a living-donor transplant). It is not medically necessary for members with listed contraindications (e.g., active vasculitis, age over 70 with severe comorbidities, ongoing substance abuse, untreated coagulation disorder), and it designates a large set of rejection-monitoring biomarkers, donor-derived cell-free DNA tests, and adjunct therapies as experimental and investigational.

Policy CPB 0493 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0493

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0493 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Kidney Transplantation (CPT 50300), and what gets it denied?

Path
Aetna CPB 0493 covers kidney transplantation as medically necessary when the member meets the transplant center's selection criteria, or in their absence, all of Aetna's listed criteria (committee acceptance, age, absence of disqualifying malignancy/infection, controlled HIV if present, acceptable cardiac/pulmonary/hepatic risk, and a severity-of-disease pathway: on dialysis, OR chronic renal failure progressing to ESRD for a cadaveric transplant, OR ESRD with creatinine clearance below 20 ml/min or uremia symptoms for a living-donor transplant). It is not medically necessary for members with listed contraindications (e.g., active vasculitis, age over 70 with severe comorbidities, ongoing substance abuse, untreated coagulation disorder), and it designates a large set of rejection-monitoring biomarkers, donor-derived cell-free DNA tests, and adjunct therapies as experimental and investigational. Coverage criteria include: Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. In the absence of an institution's selection criteria, Aetna considers kidney transplantation medically necessary when ALL of the following criteria are met.; Member has completed an evaluation and been accepted by the kidney transplant committee at the kidney transplantation center.; Member meets transplanting institution's protocol eligibility criteria regarding age.; Absence of malignancy (except for non-melanomatous skin cancers or low-grade prostate cancer) OR the malignancy has had curative therapy (e.g., surgical resection of non-invasive squamous cell or basal cell skin cancer) OR the estimated risk of recurrence of the malignancy is less than 10% within the next 2 years (for example: renal cell carcinoma treated by nephrectomy with no evidence of metastatic disease 2 years after the nephrectomy; prostate cancer with negative prostate-specific antigen levels after treatment; surgically treated colon cancer; thyroid cancer with normal thyroglobulin levels after therapy; and others). Women should have a negative Pap smear within the past 3 years and mammography, where indicated, within the past 2 years.; Absence of systemic infection.; Absence of symptomatic HIV infection, as defined by ALL of the following: CD4 count greater than 200 cells/mm3 for more than 6 months; AND HIV-1 RNA (viral load) undetectable; AND on stable anti-viral therapy for more than 3 months; AND no other complications from AIDS, such as opportunistic infection (e.g., aspergillus, coccidiomycosis, resistant fungal infections, tuberculosis), Kaposi's sarcoma or other neoplasms.; Attending physician determines that there is no prohibitive cardiovascular risk.; Attending physician determines that there is no prohibitive pulmonary risk.; Attending physician determines that there is no prohibitive hepatic risk.; Severity of disease — member meets ONE of the following: Member is already on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD); OR Member has chronic renal failure with anticipated deterioration to end stage renal disease, where member is seeking precertification for cadaveric kidney transplantation; OR Member has end stage renal disease, evidenced by a creatinine clearance below 20 ml/min or development of symptoms of uremia, and member is seeking precertification for a living donor kidney transplantation.; Pre-emptive cadaveric kidney transplantation: Given waiting periods for cadaveric donors averaging 1 to 4 years, kidney transplantation is considered medically necessary for persons with severe chronic renal failure with anticipated progression to end stage renal disease. Severe chronic renal failure is defined as a creatinine clearance of less than 30 ml/min.; For persons undergoing kidney transplantation due to diabetic nephropathy, a combined kidney/pancreas transplantation may be considered medically necessary under some circumstances (see CPB 0587 - Pancreas Kidney Transplantation).; Other multi-organ transplants (e.g., kidney/heart, liver/kidney) should be referred to Aetna's National Medical Excellence Program for review.; Aetna considers auto-transplantation and ex-vivo repair medically necessary where repair of the kidney, ureter, renal artery or its branches are not amenable to in-situ reconstruction.; Aetna considers the use of belatacept (Nulojix) medically necessary for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV).; Aetna considers equine anti-thymocyte immune globulin (Atgam) medically necessary for: Prophylaxis or treatment of allograft rejection episodes in renal transplantation in combination with conventional therapy; OR Moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation.; Aetna considers renal auto-transplantation medically necessary for the treatment of individuals with loin pain hematuria syndrome who have failed non-surgical therapies including analgesics.. Applies to 4 codes: 50300, 50320, 50360, 50365.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Kidney transplant is not considered medically necessary for persons who do not meet the transplanting institution's protocol selection criteria, or in the absence of a protocol, for persons who have ANY of the following (not an all-inclusive list): Active vasculitis.; Contraindication (not medically necessary): Age over 70 years with severe co-morbidities.; Contraindication (not medically necessary): Life threatening extra-renal congenital abnormalities.; Contraindication (not medically necessary): Ongoing alcohol or drug abuse.; Contraindication (not medically necessary): Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.; Contraindication (not medically necessary): Untreated coagulation disorder.; Experimental, investigational, or unproven: Gene microarrays (e.g., the Molecular Microscope Diagnostic System (MMDx-Kidney)) in diagnosis of rejection of kidney transplantation.; Experimental, investigational, or unproven: Measurement of cytokines (e.g., IL-1 beta, IL-2, IL-4, IL-6, GM-CSF, MCP-1, TNF-alpha) for the diagnosis of acute renal allograft rejection.; Experimental, investigational, or unproven: Clarava as a pre-transplant prognosis test for the risk of early acute rejection in kidney transplant candidates.; Experimental, investigational, or unproven: Human leukocyte antigen-G 14-base-pair-insertion/deletion polymorphism, interleukin-2 -330 T/G promoter, and interleukin-10 -1082 (G/A) promoter polymorphisms testing for evaluating the risk of developing kidney graft rejection.; Experimental, investigational, or unproven: Perfusate biomarkers produced during hypothermic machine perfusion for prediction of graft outcomes in kidney transplantation.; Experimental, investigational, or unproven: Pleximark (measurement of donor and third party-induced CD154+ T-cytotoxic memory cells) for evaluation of acute cellular rejection following kidney transplantation.; Experimental, investigational, or unproven: Tuteva as a post-transplant test for acute cellular rejection, including sub-clinical rejection, in kidney transplant recipients.; Experimental, investigational, or unproven: Bisphosphonates for the treatment of low bone mineral density after kidney transplantation.; Experimental, investigational, or unproven: Pre-conditioning therapy (e.g., immune-adsorption or rituximab) in ABO-incompatible kidney transplantation.; Experimental, investigational, or unproven: Urinary neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid-binding protein (L-FABP) as biomarkers of acute kidney injury following kidney transplantation.; Experimental, investigational, or unproven: Fas ligand (FASL) mRNA detection as a diagnostic marker for acute renal rejection.; Experimental, investigational, or unproven: Urinary biomarkers (e.g., chemokines CXCL9 and CXCL10 (e.g., One Lambda CXCL10 urine test); extracellular vesicles; MCP-1/CCL2) for detection and monitoring of renal graft rejection.; Experimental, investigational, or unproven: Donor-derived cell-free DNA testing (e.g., Allosure, Prospera Kidney, VitaGraft Kidney) for tapering immunosuppression and monitoring acute rejection following renal transplantation.; Experimental, investigational, or unproven: Measurement of angiotensin II type 1 (AT1) receptors or AT1 antibodies for evaluation of renal transplantation candidates/recipients.; Experimental, investigational, or unproven: Complement inhibitors (e.g., eculizumab) for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Belimumab for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Genotyping donors and recipients before renal transplantation.; Experimental, investigational, or unproven: Recombinant human erythropoietin (e.g., Epogen, Procrit, Retacrit) for nephron-protection in persons undergoing kidney transplantation.; Experimental, investigational, or unproven: TruGraf blood gene expression test for the management of kidney transplant recipients.; Experimental, investigational, or unproven: Plasminogen activator evaluation as part of a hypercoagulable workup prior to kidney transplantation.; Experimental, investigational, or unproven: Evaluation of urine immunocytology for T cells for the diagnosis of acute kidney rejection.; Experimental, investigational, or unproven: Measurement of pre-transplantation soluble CD30 level as a predictor of acute rejection in kidney transplantation.; Experimental, investigational, or unproven: DNA methylation as a biomarker of post-transplant complications in kidney transplantation.; Experimental, investigational, or unproven: Artificial intelligence/machine learning method for predicting graft survival in kidney transplantation.; Experimental, investigational, or unproven: Panniculectomy if used to improve kidney transplant outcomes or candidacy.; Experimental, investigational, or unproven: myOLARIS-KTdx for diagnosis and prognosis of kidney allograft rejection.; Experimental, investigational, or unproven: Belatacept for the prophylaxis of organ rejection in other transplanted organs because its effectiveness for the prevention of acute rejection in organ transplant other than kidney has not been established.; Experimental, investigational, or unproven: Equine anti-thymocyte immune globulin for all other indications. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0493 — Kidney Transplantation

Coverage criteria

  • Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. In the absence of an institution's selection criteria, Aetna considers kidney transplantation medically necessary when ALL of the following criteria are met.
  • Member has completed an evaluation and been accepted by the kidney transplant committee at the kidney transplantation center.
  • Member meets transplanting institution's protocol eligibility criteria regarding age.
  • Absence of malignancy (except for non-melanomatous skin cancers or low-grade prostate cancer) OR the malignancy has had curative therapy (e.g., surgical resection of non-invasive squamous cell or basal cell skin cancer) OR the estimated risk of recurrence of the malignancy is less than 10% within the next 2 years (for example: renal cell carcinoma treated by nephrectomy with no evidence of metastatic disease 2 years after the nephrectomy; prostate cancer with negative prostate-specific antigen levels after treatment; surgically treated colon cancer; thyroid cancer with normal thyroglobulin levels after therapy; and others). Women should have a negative Pap smear within the past 3 years and mammography, where indicated, within the past 2 years.
  • Absence of systemic infection.
  • Absence of symptomatic HIV infection, as defined by ALL of the following: CD4 count greater than 200 cells/mm3 for more than 6 months; AND HIV-1 RNA (viral load) undetectable; AND on stable anti-viral therapy for more than 3 months; AND no other complications from AIDS, such as opportunistic infection (e.g., aspergillus, coccidiomycosis, resistant fungal infections, tuberculosis), Kaposi's sarcoma or other neoplasms.
  • Attending physician determines that there is no prohibitive cardiovascular risk.
  • Attending physician determines that there is no prohibitive pulmonary risk.
  • Attending physician determines that there is no prohibitive hepatic risk.
  • Severity of disease — member meets ONE of the following: Member is already on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD); OR Member has chronic renal failure with anticipated deterioration to end stage renal disease, where member is seeking precertification for cadaveric kidney transplantation; OR Member has end stage renal disease, evidenced by a creatinine clearance below 20 ml/min or development of symptoms of uremia, and member is seeking precertification for a living donor kidney transplantation.
  • Pre-emptive cadaveric kidney transplantation: Given waiting periods for cadaveric donors averaging 1 to 4 years, kidney transplantation is considered medically necessary for persons with severe chronic renal failure with anticipated progression to end stage renal disease. Severe chronic renal failure is defined as a creatinine clearance of less than 30 ml/min.
  • For persons undergoing kidney transplantation due to diabetic nephropathy, a combined kidney/pancreas transplantation may be considered medically necessary under some circumstances (see CPB 0587 - Pancreas Kidney Transplantation).
  • Other multi-organ transplants (e.g., kidney/heart, liver/kidney) should be referred to Aetna's National Medical Excellence Program for review.
  • Aetna considers auto-transplantation and ex-vivo repair medically necessary where repair of the kidney, ureter, renal artery or its branches are not amenable to in-situ reconstruction.
  • Aetna considers the use of belatacept (Nulojix) medically necessary for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV).
  • Aetna considers equine anti-thymocyte immune globulin (Atgam) medically necessary for: Prophylaxis or treatment of allograft rejection episodes in renal transplantation in combination with conventional therapy; OR Moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation.
  • Aetna considers renal auto-transplantation medically necessary for the treatment of individuals with loin pain hematuria syndrome who have failed non-surgical therapies including analgesics.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Kidney Transplantation (CPT 50300), and what gets it denied?
Aetna CPB 0493 covers kidney transplantation as medically necessary when the member meets the transplant center's selection criteria, or in their absence, all of Aetna's listed criteria (committee acceptance, age, absence of disqualifying malignancy/infection, controlled HIV if present, acceptable cardiac/pulmonary/hepatic risk, and a severity-of-disease pathway: on dialysis, OR chronic renal failure progressing to ESRD for a cadaveric transplant, OR ESRD with creatinine clearance below 20 ml/min or uremia symptoms for a living-donor transplant). It is not medically necessary for members with listed contraindications (e.g., active vasculitis, age over 70 with severe comorbidities, ongoing substance abuse, untreated coagulation disorder), and it designates a large set of rejection-monitoring biomarkers, donor-derived cell-free DNA tests, and adjunct therapies as experimental and investigational. Coverage criteria include: Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. In the absence of an institution's selection criteria, Aetna considers kidney transplantation medically necessary when ALL of the following criteria are met.; Member has completed an evaluation and been accepted by the kidney transplant committee at the kidney transplantation center.; Member meets transplanting institution's protocol eligibility criteria regarding age.; Absence of malignancy (except for non-melanomatous skin cancers or low-grade prostate cancer) OR the malignancy has had curative therapy (e.g., surgical resection of non-invasive squamous cell or basal cell skin cancer) OR the estimated risk of recurrence of the malignancy is less than 10% within the next 2 years (for example: renal cell carcinoma treated by nephrectomy with no evidence of metastatic disease 2 years after the nephrectomy; prostate cancer with negative prostate-specific antigen levels after treatment; surgically treated colon cancer; thyroid cancer with normal thyroglobulin levels after therapy; and others). Women should have a negative Pap smear within the past 3 years and mammography, where indicated, within the past 2 years.; Absence of systemic infection.; Absence of symptomatic HIV infection, as defined by ALL of the following: CD4 count greater than 200 cells/mm3 for more than 6 months; AND HIV-1 RNA (viral load) undetectable; AND on stable anti-viral therapy for more than 3 months; AND no other complications from AIDS, such as opportunistic infection (e.g., aspergillus, coccidiomycosis, resistant fungal infections, tuberculosis), Kaposi's sarcoma or other neoplasms.; Attending physician determines that there is no prohibitive cardiovascular risk.; Attending physician determines that there is no prohibitive pulmonary risk.; Attending physician determines that there is no prohibitive hepatic risk.; Severity of disease — member meets ONE of the following: Member is already on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD); OR Member has chronic renal failure with anticipated deterioration to end stage renal disease, where member is seeking precertification for cadaveric kidney transplantation; OR Member has end stage renal disease, evidenced by a creatinine clearance below 20 ml/min or development of symptoms of uremia, and member is seeking precertification for a living donor kidney transplantation.; Pre-emptive cadaveric kidney transplantation: Given waiting periods for cadaveric donors averaging 1 to 4 years, kidney transplantation is considered medically necessary for persons with severe chronic renal failure with anticipated progression to end stage renal disease. Severe chronic renal failure is defined as a creatinine clearance of less than 30 ml/min.; For persons undergoing kidney transplantation due to diabetic nephropathy, a combined kidney/pancreas transplantation may be considered medically necessary under some circumstances (see CPB 0587 - Pancreas Kidney Transplantation).; Other multi-organ transplants (e.g., kidney/heart, liver/kidney) should be referred to Aetna's National Medical Excellence Program for review.; Aetna considers auto-transplantation and ex-vivo repair medically necessary where repair of the kidney, ureter, renal artery or its branches are not amenable to in-situ reconstruction.; Aetna considers the use of belatacept (Nulojix) medically necessary for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV).; Aetna considers equine anti-thymocyte immune globulin (Atgam) medically necessary for: Prophylaxis or treatment of allograft rejection episodes in renal transplantation in combination with conventional therapy; OR Moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation.; Aetna considers renal auto-transplantation medically necessary for the treatment of individuals with loin pain hematuria syndrome who have failed non-surgical therapies including analgesics.. Applies to 4 codes: 50300, 50320, 50360, 50365. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Kidney transplant is not considered medically necessary for persons who do not meet the transplanting institution's protocol selection criteria, or in the absence of a protocol, for persons who have ANY of the following (not an all-inclusive list): Active vasculitis.; Contraindication (not medically necessary): Age over 70 years with severe co-morbidities.; Contraindication (not medically necessary): Life threatening extra-renal congenital abnormalities.; Contraindication (not medically necessary): Ongoing alcohol or drug abuse.; Contraindication (not medically necessary): Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.; Contraindication (not medically necessary): Untreated coagulation disorder.; Experimental, investigational, or unproven: Gene microarrays (e.g., the Molecular Microscope Diagnostic System (MMDx-Kidney)) in diagnosis of rejection of kidney transplantation.; Experimental, investigational, or unproven: Measurement of cytokines (e.g., IL-1 beta, IL-2, IL-4, IL-6, GM-CSF, MCP-1, TNF-alpha) for the diagnosis of acute renal allograft rejection.; Experimental, investigational, or unproven: Clarava as a pre-transplant prognosis test for the risk of early acute rejection in kidney transplant candidates.; Experimental, investigational, or unproven: Human leukocyte antigen-G 14-base-pair-insertion/deletion polymorphism, interleukin-2 -330 T/G promoter, and interleukin-10 -1082 (G/A) promoter polymorphisms testing for evaluating the risk of developing kidney graft rejection.; Experimental, investigational, or unproven: Perfusate biomarkers produced during hypothermic machine perfusion for prediction of graft outcomes in kidney transplantation.; Experimental, investigational, or unproven: Pleximark (measurement of donor and third party-induced CD154+ T-cytotoxic memory cells) for evaluation of acute cellular rejection following kidney transplantation.; Experimental, investigational, or unproven: Tuteva as a post-transplant test for acute cellular rejection, including sub-clinical rejection, in kidney transplant recipients.; Experimental, investigational, or unproven: Bisphosphonates for the treatment of low bone mineral density after kidney transplantation.; Experimental, investigational, or unproven: Pre-conditioning therapy (e.g., immune-adsorption or rituximab) in ABO-incompatible kidney transplantation.; Experimental, investigational, or unproven: Urinary neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid-binding protein (L-FABP) as biomarkers of acute kidney injury following kidney transplantation.; Experimental, investigational, or unproven: Fas ligand (FASL) mRNA detection as a diagnostic marker for acute renal rejection.; Experimental, investigational, or unproven: Urinary biomarkers (e.g., chemokines CXCL9 and CXCL10 (e.g., One Lambda CXCL10 urine test); extracellular vesicles; MCP-1/CCL2) for detection and monitoring of renal graft rejection.; Experimental, investigational, or unproven: Donor-derived cell-free DNA testing (e.g., Allosure, Prospera Kidney, VitaGraft Kidney) for tapering immunosuppression and monitoring acute rejection following renal transplantation.; Experimental, investigational, or unproven: Measurement of angiotensin II type 1 (AT1) receptors or AT1 antibodies for evaluation of renal transplantation candidates/recipients.; Experimental, investigational, or unproven: Complement inhibitors (e.g., eculizumab) for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Belimumab for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Genotyping donors and recipients before renal transplantation.; Experimental, investigational, or unproven: Recombinant human erythropoietin (e.g., Epogen, Procrit, Retacrit) for nephron-protection in persons undergoing kidney transplantation.; Experimental, investigational, or unproven: TruGraf blood gene expression test for the management of kidney transplant recipients.; Experimental, investigational, or unproven: Plasminogen activator evaluation as part of a hypercoagulable workup prior to kidney transplantation.; Experimental, investigational, or unproven: Evaluation of urine immunocytology for T cells for the diagnosis of acute kidney rejection.; Experimental, investigational, or unproven: Measurement of pre-transplantation soluble CD30 level as a predictor of acute rejection in kidney transplantation.; Experimental, investigational, or unproven: DNA methylation as a biomarker of post-transplant complications in kidney transplantation.; Experimental, investigational, or unproven: Artificial intelligence/machine learning method for predicting graft survival in kidney transplantation.; Experimental, investigational, or unproven: Panniculectomy if used to improve kidney transplant outcomes or candidacy.; Experimental, investigational, or unproven: myOLARIS-KTdx for diagnosis and prognosis of kidney allograft rejection.; Experimental, investigational, or unproven: Belatacept for the prophylaxis of organ rejection in other transplanted organs because its effectiveness for the prevention of acute rejection in organ transplant other than kidney has not been established.; Experimental, investigational, or unproven: Equine anti-thymocyte immune globulin for all other indications. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Kidney Transplantation?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Kidney Transplantation?
Policy exclusions and limitations: Kidney transplant is not considered medically necessary for persons who do not meet the transplanting institution's protocol selection criteria, or in the absence of a protocol, for persons who have ANY of the following (not an all-inclusive list): Active vasculitis.; Contraindication (not medically necessary): Age over 70 years with severe co-morbidities.; Contraindication (not medically necessary): Life threatening extra-renal congenital abnormalities.; Contraindication (not medically necessary): Ongoing alcohol or drug abuse.; Contraindication (not medically necessary): Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.; Contraindication (not medically necessary): Untreated coagulation disorder.; Experimental, investigational, or unproven: Gene microarrays (e.g., the Molecular Microscope Diagnostic System (MMDx-Kidney)) in diagnosis of rejection of kidney transplantation.; Experimental, investigational, or unproven: Measurement of cytokines (e.g., IL-1 beta, IL-2, IL-4, IL-6, GM-CSF, MCP-1, TNF-alpha) for the diagnosis of acute renal allograft rejection.; Experimental, investigational, or unproven: Clarava as a pre-transplant prognosis test for the risk of early acute rejection in kidney transplant candidates.; Experimental, investigational, or unproven: Human leukocyte antigen-G 14-base-pair-insertion/deletion polymorphism, interleukin-2 -330 T/G promoter, and interleukin-10 -1082 (G/A) promoter polymorphisms testing for evaluating the risk of developing kidney graft rejection.; Experimental, investigational, or unproven: Perfusate biomarkers produced during hypothermic machine perfusion for prediction of graft outcomes in kidney transplantation.; Experimental, investigational, or unproven: Pleximark (measurement of donor and third party-induced CD154+ T-cytotoxic memory cells) for evaluation of acute cellular rejection following kidney transplantation.; Experimental, investigational, or unproven: Tuteva as a post-transplant test for acute cellular rejection, including sub-clinical rejection, in kidney transplant recipients.; Experimental, investigational, or unproven: Bisphosphonates for the treatment of low bone mineral density after kidney transplantation.; Experimental, investigational, or unproven: Pre-conditioning therapy (e.g., immune-adsorption or rituximab) in ABO-incompatible kidney transplantation.; Experimental, investigational, or unproven: Urinary neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid-binding protein (L-FABP) as biomarkers of acute kidney injury following kidney transplantation.; Experimental, investigational, or unproven: Fas ligand (FASL) mRNA detection as a diagnostic marker for acute renal rejection.; Experimental, investigational, or unproven: Urinary biomarkers (e.g., chemokines CXCL9 and CXCL10 (e.g., One Lambda CXCL10 urine test); extracellular vesicles; MCP-1/CCL2) for detection and monitoring of renal graft rejection.; Experimental, investigational, or unproven: Donor-derived cell-free DNA testing (e.g., Allosure, Prospera Kidney, VitaGraft Kidney) for tapering immunosuppression and monitoring acute rejection following renal transplantation.; Experimental, investigational, or unproven: Measurement of angiotensin II type 1 (AT1) receptors or AT1 antibodies for evaluation of renal transplantation candidates/recipients.; Experimental, investigational, or unproven: Complement inhibitors (e.g., eculizumab) for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Belimumab for the treatment of antibody-mediated rejection in renal transplantation recipients.; Experimental, investigational, or unproven: Genotyping donors and recipients before renal transplantation.; Experimental, investigational, or unproven: Recombinant human erythropoietin (e.g., Epogen, Procrit, Retacrit) for nephron-protection in persons undergoing kidney transplantation.; Experimental, investigational, or unproven: TruGraf blood gene expression test for the management of kidney transplant recipients.; Experimental, investigational, or unproven: Plasminogen activator evaluation as part of a hypercoagulable workup prior to kidney transplantation.; Experimental, investigational, or unproven: Evaluation of urine immunocytology for T cells for the diagnosis of acute kidney rejection.; Experimental, investigational, or unproven: Measurement of pre-transplantation soluble CD30 level as a predictor of acute rejection in kidney transplantation.; Experimental, investigational, or unproven: DNA methylation as a biomarker of post-transplant complications in kidney transplantation.; Experimental, investigational, or unproven: Artificial intelligence/machine learning method for predicting graft survival in kidney transplantation.; Experimental, investigational, or unproven: Panniculectomy if used to improve kidney transplant outcomes or candidacy.; Experimental, investigational, or unproven: myOLARIS-KTdx for diagnosis and prognosis of kidney allograft rejection.; Experimental, investigational, or unproven: Belatacept for the prophylaxis of organ rejection in other transplanted organs because its effectiveness for the prevention of acute rejection in organ transplant other than kidney has not been established.; Experimental, investigational, or unproven: Equine anti-thymocyte immune globulin for all other indications. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0493 — Kidney Transplantation

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0493 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.