MedicaidCoverageMedium impact
Autologous Islet Cell Transplant - MEDICAID - VIRGINIA (New)
Humana·VA · Gastroenterology, General Surgery, Endocrinology +1 more·Medicaid
Effective date
Oct 28, 2026
We identified it
Oct 26, 2026
Summary
Humana Medicaid in Virginia is introducing a new coverage policy (HUM-VA-2664-001) for autologous islet cell transplant (pancreatectomy with islet autotransplantation) effective 2026-10-28. The policy covers this procedure for members under 21 with chronic pancreatitis meeting strict clinical criteria, including intractable pain with impaired quality of life and failed prior interventions, while excluding candidates with active substance use, uncontrolled psychiatric illness, C-peptide negative diabetes, high-risk cardiopulmonary disease, pancreatic cancer, portal hypertension/thrombosis, significant liver disease, or Type 1 diabetes. Billing teams must recognize this new covered service and apply the specific eligibility criteria and CPT code (48160) for claim submission.
Action Required
Effective 2026-10-28: Billing team and prior authorization staff must update coverage guidelines and claim processing workflows to recognize CPT 48160 (pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells) as a covered service under Humana Medicaid in Virginia. Implement prior authorization review processes to verify member age (under 21), chronic pancreatitis diagnosis, intractable pain with impaired quality of life, failed prior endoscopic/medical/surgical therapy, and absence of exclusionary conditions (active alcoholism, active illicit substance use, untreated psychiatric illness, C-peptide negative diabetes, high-risk cardiopulmonary disease, pancreatic cancer, portal hypertension, portal vein thrombosis, significant liver disease, Type 1 diabetes). For pediatric members, ensure EPSDT requirements are evaluated to confirm the intervention will correct or ameliorate the member's condition. Update billing system templates and provider communication materials to reflect this new coverage. Verify current applicability with Humana before processing initial claims.