All PlansPrior AuthHigh impact
Kidney Transplantation 7.02.04
Excellus BlueCross BlueShield·Nephrology, Urology, General Surgery +1 more·Transplants
Effective date
Apr 16, 2026
We identified it
Jun 20, 2026
Summary
New kidney transplantation policy 7.02.04 establishes comprehensive criteria for transplant coverage including specific GFR thresholds, contraindications, and detailed pre-authorization requirements. The policy requires extensive documentation including performance scores, cardiac assessments, and annual re-authorization for waitlisted patients.
Action Required
Before April 16, 2026: Billing team must implement prior authorization requirements for all kidney transplants. Update billing system to flag kidney transplant cases for pre-auth documentation including GFR levels ≤20ml/min or dialysis initiation, performance scores (Karnofsky, PPS, ECOG, or Lansky), cardiac assessments, lab tests, and psycho-social evaluations. Establish annual re-authorization tracking for waitlisted patients. Claims will be denied without proper pre-authorization and documentation.