Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Heart and Kidney disease.
Treatment:  Surgical Procedure on the Kidney (kidney transplant and inpatient admission).

The insurer denied coverage for surgical Procedure on the Kidney (kidney transplant and inpatient admission).  The denial is modified.

Based upon the information provided, the patient would not meet criteria for coverage for kidney surgery alone based on national guidelines as the glomerular filtration rate (GFR) is above 20. The patient does however need a heart transplant and would meet criteria for a combined kidney/heart transplant based upon the present kidney function. 
	
Kobashigawa noted that for accurate measurement of GFR, two independent measurements for GFR at least 2 weeks apart are suggested to evaluate if patients meet the criteria for Simultaneous Heart/Kidney (sHK). Given the medical history of this patient and the need for a heart transplant with evidence of renal insufficiency with a Cystatin level of 25, the patient does qualify for a combined kidney heart transplant.
	
Mancini noted that the indications for combined organ transplantation include patients with severe irreversible disease of the heart and another organ system, multiorgan transplantation may be an option in some of these cases but requires careful consideration given the complex medical issues involved. The author also noted that patients with end-stage heart disease who also have renal failure with indication for kidney transplantation can be considered for dual organ transplantation. In this case the patient should be considered for combined kidney/heart transplant and not kidney only.
	
Rossi noted that severe ischemic cardiomyopathy (ejection fraction <30%) is a relative contraindication to kidney transplantation. Combined kidney/heart transplantation may be considered in select patients who require transplantation of both organs. In addition, the patient should be free of all untreated, active infection before transplantation. Dental infections should be treated prior to transplantation. This patient meets the guidelines for a combined kidney/heart and not kidney alone. In terms of the dental workup the patient has gone to the dentist and is in the process of having several teeth extracted. 
	
Allen noted that Epstein-Barr virus (EBV) serostatus should be determined on all transplant recipients and donors in order to identify the patients at high risk for post-transplant lymphoproliferative disorder (PTLD) development (Strong/high). This patient has an EBV Immunoglobulin G (IgG) antibody meaning that the patient is immune and therefore does not require any further testing. This should not be a hindrance for the patient to get a combined kidney/heart transplant.

The reviewer, therefore, disagrees with the insurer and feels the kidney surgery in the form of a kidney transplant is medically indicated for this patient as a combined kidney/heart transplant and the patient does meet listing criteria for the transplant program pending the teeth extraction. The reviewer is knowledgeable in this condition and the recommended health care services provided for this condition. The reviewer does believe that based upon these findings the health care plan did not act reasonably and with sound medical judgment. The criteria utilized included own personal experience as to what constitutes good acceptable standard of care and Milliman Care Guidelines. The denial is therefore reversed for combined kidney/heart transplant pending the teeth extraction. The patient is not approved for a kidney only transplant.

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Surgical Procedure only on the Kidney (kidney transplant and inpatient admission) is not substantiated.  However as noted, it is overturned for a combined kidney/heart transplant.