Pancreas Transplantation Alone (PTA) and Islet Cell Transplantation (CPB 0601, reviewed 2025-09-10)

Immediately: 1) Billing team must establish precertification requirement for Lantidra (CPT 0584T, 0585T, 0586T) through NME at 877-212-8811 prior to claim submission. 2) Update billing software and encounter forms to flag all islet cell transplantation claims for precertification and to track Lantidra infusion count (limited to maximum 3 per member lifetime). 3) Providers must document that members meet all initial approval criteria (age 18+, type 1 diabetes, repeated severe hypoglycemia despite intensive management, no prior renal transplant) before submitting claims. 4) Ensure all PTA claims include documentation of: labile IDDM history, recurrent severe metabolic complications, and documented failure of exogenous insulin-based management (HbA1c >8.0 or recurrent hypoglycemic unawareness). 5) Implement absolute contraindication screening: deny or refer for review any claims where member has angiographic evidence of significant non-correctable coronary artery disease, ejection fraction <35%, MI within 6 months, or refractory uncontrolled hypertension. 6) For relative contraindications (ejection fraction 35-40%, severe peripheral vascular disease, or inability to adhere to regimen), require physician attestation that benefits outweigh risks; for substance abuse/psychiatric issues, require supporting documentation of 3 months stability from addiction professional or psychiatrist within 4 weeks. Claims submitted without required precertification, medical necessity documentation, or contraindication review will be denied.