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Intestinal Rehabilitation Programs
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Defines Aetna's coverage stance for multidisciplinary intestinal rehabilitation programs, specifying medical necessity for persons with parenteral nutrition-dependent intestinal failure and investigational status for other indications; intended for clinicians and benefits reviewers contracting with Aetna.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical Necessity — Covered when ALL of the following are met
Covered when ALL of the following are met
Aetna considers multidisciplinary intestinal rehabilitation programs medically necessary for persons with parenteral nutrition-dependent intestinal failure.
Experimental and Investigational — Not covered when the following apply
Not covered when the following apply
Aetna considers intestinal rehabilitation programs experimental and investigational for all other indications.
The policy lists related billing codes and diagnostic codes that may be relevant when selection criteria are met. Relevant HCPCS and CPT codes include transplant and home infusion/TPN administrative codes such as S2053 and S9364–S9368, and CPT codes for intestinal allotransplantation and related procedures (44135–44137, 44615). ICD-10 codes called out in the policy include those that may be covered when selection criteria are met (for example, K91.2), as well as ICD-10 codes noted as not covered for the indications listed (examples include E41, E43–E46, E64.0 for malnutrition; K50.00–K50.919, K51.00–K51.919 for inflammatory bowel disease; K52.0; and vascular disorders of the intestine K55.011–K55.1, K55.8–K55.9).
This Clinical Policy Bulletin addresses multidisciplinary intestinal rehabilitation programs and is intended to assist in administering plan benefits. It states Aetna’s coverage stance: multidisciplinary intestinal rehabilitation programs are medically necessary for persons with parenteral nutrition-dependent intestinal failure, and are considered experimental and investigational for all other indications. Providers should verify member coverage and obtain any required prior authorization from the member’s plan, since the bulletin provides a general description of benefits and does not constitute a contract or guarantee coverage.
Aetna considers intestinal rehabilitation programs experimental and investigational for all indications other than parenteral nutrition-dependent intestinal failure. Services billed for indications outside of parenteral nutrition-dependent intestinal failure may be denied as not medically necessary; additionally, certain ICD-10 diagnoses are specifically noted in the policy as not covered for the listed indications and should not be used to justify coverage outside the stated selection criteria.
Coding
| 44135 | Intestinal allotransplantation |
| 44136 | Intestinal allotransplantation |
| 44137 | Removal of transplanted intestinal allograft, complete |
| 44615 | Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation |
| S2053 | Transplant of small intestine, and liver allografts |
| S9364 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment |
| S9365 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment |
| S9366 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment |
| S9367 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment |
| S9368 | Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment |
Provider Actions and Requirements
Prior authorization may be required for related transplant / home TPN services
Certain HCPCS transplant and home infusion/TPN administrative codes are listed as related codes; confirm prior authorization requirements for transplant or home TPN services with Aetna.
Verify coverage and obtain prior authorization
Providers should verify the member's coverage and obtain any prior authorization required by the member's plan before initiating multidisciplinary intestinal rehabilitation services.
- Clinical Policy Bulletins are intended to assist in administering benefits but do not replace plan-specific authorization requirements.
- Obtain plan-specific prior authorization when required by the member’s benefits.
Step therapy
No step therapy requirements are specified in this portion of the policy.
Provider note
Reserved note for provider-facing guidance; see plan documents and contact Aetna for patient-specific questions.
Coding and diagnostic documentation
Document diagnoses and relevant codes when selection criteria are met; the policy lists related CPT/HCPCS/ICD-10 codes (including Z90.49 and K91.2) that may be relevant to support medical necessity.
- Document parenteral nutrition–dependent intestinal failure and supporting clinical details.
- Relevant ICD-10 examples: Z90.49, K91.2; Malnutrition codes and other listed ICD-10 codes may be applicable as noted in the CPB.
Provider responsibility and plan verification
Treating providers are solely responsible for medical advice and treatment; providers must verify plan benefits and follow plan-specific documentation and member ID guidance for authorization.
- Follow plan/program terms and member-specific benefit rules when requesting services.
- Ensure documentation supports parenteral nutrition–dependent intestinal failure to meet medical necessity criteria.
Denial risk for non‑covered indications
Services for intestinal rehabilitation programs billed for indications other than parenteral nutrition–dependent intestinal failure are considered experimental/investigational and may be denied.
- Confirm the indication is parenteral nutrition–dependent intestinal failure before billing to reduce risk of denial.
Coverage subject to plan/program terms
Coverage described in this Clinical Policy Bulletin is subject to plan/program terms and does not guarantee benefits; confirm individual member coverage and eligibility.
- This CPB provides general guidance and does not constitute a contract or guarantee of coverage.
Background
Intestinal rehabilitation seeks to promote adaptation of the remaining small intestine after extensive resection (short-bowel syndrome) and to support patients with intestinal failure. Multidisciplinary programs coordinate nutritional optimization, medical and surgical management, and supportive care with the aim of reducing dependence on chronic total parenteral nutrition (TPN), lowering TPN-associated complications, improving survival, and optimizing timing for transplant when necessary. Aetna’s policy specifically frames these programs as medically necessary when the patient has parenteral nutrition-dependent intestinal failure and otherwise considers the programs investigational for other indications.
Definitions
Revision History
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