Does Medicare Cover a Pancreas Transplant?

A pancreas transplant offers a potential cure for type 1 diabetes, but this surgery is reserved for people who live with severe secondary complications from diabetes, including kidney failure.  Any organ transplant comes with significant risks, including blood clots, infection, organ failure or rejection, or urinary complications, but if your physician considers it medically necessary, understanding your Medicare coverage may help alleviate some of the stress involved.

What is a pancreas transplant?

The pancreas is the organ located behind the lower part of your stomach that makes insulin, a hormone that regulates the absorption of sugar (glucose) into your cells. When the pancreas is not functioning, your sugar levels can get dangerously high, leading to type 1 diabetes. If a transplant is the only option, the pancreas will be replaced by a healthy one from a deceased donor.

Different types of pancreas transplants include:

• Stand-alone pancreas transplant
• Combined kidney-pancreas transplant
• Pancreas after kidney transplant
• Pancreatic islet cell transplant

How will Medicare help cover the costs of a pancreas transplant?

According to the Centers for Medicare & Medicaid Services, whole organ pancreas transplantation is nationally covered when performed simultaneously with or after a kidney transplant. Immunosuppressive therapy begins with the date of discharge from your inpatient stay for the pancreas transplant. Transplants that are performed alone are also covered in the following circumstances:

• The transplant is considered reasonable and necessary
• The transplant takes place in a Medicare-approved facility
• Patients must have a type 1 diabetes diagnosis with medically-uncontrollable complications
• Patients must have been optimally and intensively managed by an endocrinologist for at least 12 months with the most medically-recognized advanced insulin formulations and delivery systems
• Patients must have the mental and emotional capacity to understand the risks associated with surgery and the need for lifetime immunosuppressive drugs
• Patients must be a suitable candidate for transplantation

What services will Medicare cover?

Medicare Part A and Part B helps cover the costs of:

• Doctor services for organ transplants
• Necessary tests, exams, office visits
• Follow-up care
• Procurement of organs
• Transplant drugs

If you have Original Medicare, you will pay 20% of the Medicare-approved amount, and will be responsible for the Part B deductible. If you are enrolled in a Medicare Advantage (MA) plan, you will have at least the same benefits as Original Medicare, but many MA plans include additional benefits.

If you only have Medicare due to permanent kidney failure, Medicare coverage for immunosuppressive drugs may end after 36 months after the month of the kidney transplant.