Diagnosis: Kidney Failure
Treatment: Kidney transplant
The insurer denied: Kidney transplant
The denial is overturned

The patient is an adult female with kidney failure secondary to diabetic nephropathy and the treating physician requested kidney transplant.

The kidney transplant is medically necessary.

This is a patient with end stage renal disease without reversible cause and no contraindication to kidney transplant. This request is medically necessary per evidence-based literature. A systematic review of 110 studies encompassing almost 2 million patients concluded that kidney transplant was associated with better quality of life, fewer cardiovascular events, and lower long-term all-cause mortality as compared to chronic dialysis. [1]
A study of 960 elderly (older than 65 years, mean age 71 years) propensity-matched patients with renal failure treated with home dialysis or renal transplant found a 4.7-fold higher mortality risk among the patients treated with home dialysis.[2]
Cadaveric and expanded criteria donor kidneys are appropriate when living donors are not available and for the elderly in whom the graft may last the lifetime of the recipient. [3]
Therefore, the requested kidney transplant is medically necessary.