Find policies, billing codes, payers, states, and providers
Intestinal Transplantation
Customize your policy alerts
Sign up for Aetna Policy 0605 alerts
Get alerted when Policy 0605 changes without checking for updates manually.
Monitor payer policy activity
Aetna's clinical policy on when intestinal, combined intestinal-liver, and multi-visceral transplantation are considered medically necessary, investigational, or not medically necessary; includes selection criteria, contraindications, and related coding. Affects members under Aetna's coverage and providers seeking authorization.
No material clinical or coverage changes in this revision.
Coverage Criteria for Intestinal and Multivisceral Transplantation
Initial transplant medical necessity
Covered when ALL of the following are met for persons with clinical indicators of failed TPN:
Combined intestinal and liver transplant
Combined transplant
Multi-visceral transplant coverage
Multi-visceral transplant
Indications / Candidate scenarios
Candidate consideration described in referenced studies (examples of clinical scenarios where transplant is performed):
Sources: Mangus et al. 2013; Varkey et al. 2013; Kubal et al. 2015a
Monitoring and surveillance
Monitoring and risk considerations:
Intestinal transplantation is not medically necessary for persons who have listed contraindications. Contraindications include advanced neurological disorders (for example, neuroaxonal dystrophy, Tay‑Sachs disease, Niemann‑Pick disease and variants, neuronal ceroid lipofuscinosis, Huntington disease), congestive heart failure with refractory symptoms and left ventricular ejection fraction <40%, malignancy not effectively treated with substantial risk of recurrence, multi‑organ failure, presence of other significant gastrointestinal diseases (e.g., bleeding peptic ulcer, diverticulitis, chronic hepatitis), sepsis, and unstable alcohol or substance use disorder (exceptions allowed with documentation of ≥3 months stability). Specific ICD‑10 diagnoses and substance‑use codes are listed in the coding section as contraindicated for this policy.
Comparative outcomes from cited series indicate that adult patients who are stable on parenteral nutrition/home TPN may have higher survival than adults who undergo intestinal transplantation in some cohorts. This finding supports careful candidate selection and consideration of continued conservative management for adults who are clinically stable on PN rather than routine referral to transplantation.
Measurement of fecal calprotectin for the purpose of detecting intestinal allograft rejection is considered experimental/investigational and not medically necessary, because its clinical value has not been established.
A 2015 UpToDate review of intestinal and multivisceral transplantation did not mention routine monitoring of donor‑specific anti‑HLA antibodies (DSA) as a standard management tool, indicating limited consensus and supporting a lack of routine requirement for DSA surveillance in standard care.
Coding — Covered and Not Covered Codes
| 44132 | Donor enterectomy (including cold preservation), open; from cadaver donor. |
| 44133 | partial, from living donor. |
| 44135 | Intestinal allotransplantation; from cadaver donor. |
| 44136 | from living donor. |
| 44137 | Removal of transplanted intestinal allograft, complete. |
| 44715 | Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein. |
| 44720 | Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastamosis, each. |
| 44721 | arterial anastamosis, each. |
| 36555-36597 | Central venous access procedures. |
| 47135 | Liver allotransplantation; orthotopic; partial or whole, from cadaver or living donor, any age. |
| A40.0-A40.9 | Streptococcal sepsis. |
| E86.0-E86.9 | Volume depletion. |
| I82.811-I82.91 | Embolism and thrombosis of other specified veins. |
| K91.2 | Postsurgical malabsorption, not elsewhere classified. |
| Z90.49 | Acquired absence of other specified parts of digestive tract. |
| 83993 | Calprotectin, fecal. |
| B18.0-B18.2 | Chronic viral hepatitis B and C codes listed as not covered. |
| C78.6 | Secondary malignant neoplasm of retroperitoneum and peritoneum [recurrent non-resectable pseudomyxoma peritonei]. |
| F10.10-F19.988 | Mental and behavioral disorders due to psychoactive substance use (listed as contraindicated). |
Provider Actions, Prior Authorization and Documentation
Prior Authorization Required
Prior authorization is required for intestinal transplant-related procedure codes. Requests must include documentation that the member meets selection criteria and that the transplanting institution's protocol (if any) deems the candidate eligible.
Prior Authorization: Candidate Failure of Non‑Transplant Therapy
Prior authorization requests must confirm that the candidate has failed non‑transplant therapies or has specific indications for transplant (for example: parenteral nutrition–associated liver disease, recurrent central line sepsis, threatened loss of central venous access, or other life‑threatening complications of TPN).
- Documented failure of intestinal rehabilitation and/or prolonged dependence on TPN despite optimal medical management.
- Evidence of complications from TPN such as recurrent line infections (≥2 episodes of systemic sepsis per year), impending or overt TPN‑induced liver failure, loss of central venous access, or thrombosis of major central veins (≥2 vessels).
Candidate Selection Impacts Approval
Aetna considers candidate selection (age, stability on TPN, presence of comorbidities) when making approval decisions. Outcomes differ between adults and children; adults who are stable on parenteral nutrition may not uniformly benefit from transplant whereas transplantation is often life‑saving in children.
- Approval is influenced by overall prognosis, response to conservative therapy, and center‑specific eligibility criteria.
- Multivisceral or combined transplants may be considered when indicated (e.g., simultaneous liver involvement).
Required Documentation
Required documentation must be submitted with prior authorization requests. If the transplanting institution has an eligibility protocol, include that protocol or documentation demonstrating that the member meets Aetna's selection criteria.
- Transplant center eligibility protocol (if available) or a statement addressing each Aetna selection criterion.
- Operative reports and prior surgical history relevant to intestinal failure and vascular access.
Required Clinical Documentation
Clinical documentation should fully describe the indication and prior therapies, include relevant laboratory and imaging data, and document the multidisciplinary evaluation and optimization prior to transplant.
- Indication for transplant and chronology of intestinal failure.
- Details of prior therapies including duration and complications of TPN, attempts at intestinal rehabilitation, home TPN management records.
- Laboratory data: liver function tests (including bilirubin), renal function and creatinine clearance, HIV status (CD4 count and viral load if applicable).
- Infection history: number and dates of line infections, episodes of fungemia, sepsis or septic shock.
- Cardiovascular assessment: ejection fraction or other evidence of adequate cardiac function.
- Evidence of vascular access problems or central venous thrombosis.
- Psychiatric evaluation documenting absence of untreated disorders that would impair compliance.
TPN and Conservative Management Before Transplant
Parenteral nutrition (including home TPN) and conservative management are the expected initial therapies. Intestinal transplantation is generally considered only after failure of these conservative measures and intestinal rehabilitation.
- Documented trial and management of parenteral nutrition/home TPN and outcomes.
- Documentation of intestinal rehabilitation efforts and reasons for failure or intolerance.
- Transplant may be considered earlier in pediatrics when progressive liver disease or life‑threatening complications are present.
Background and Definitions
Intestinal failure—most commonly from short bowel syndrome or severe motility disorders—results in inability to maintain adequate nutrition, fluids, and electrolytes via the enteral route. Parenteral nutrition/home TPN is the primary therapy for these patients, but life‑threatening complications of TPN (for example, recurrent central line sepsis, TPN‑associated liver disease, loss of vascular access) can indicate failure of conservative management and consideration of transplant. Outcomes after intestinal and multivisceral transplantation vary, and pediatric candidates may experience different survival benefit compared with adults.
Candidate Selection Criteria
Isolated intestinal transplant candidates
Candidates for isolated intestinal transplant
Candidate groups
Patient groups more likely to benefit:
Varkey et al. 2013; clinical series
Mangus et al. 2013; Kubal et al. 2015a
Contraindications to Transplantation
The policy lists both absolute and relative contraindications that should be considered during candidate evaluation. These include advanced neurological disorders (specific neurodegenerative diseases are named), congestive heart failure with refractory symptoms and ejection fraction <40%, active or inadequately treated malignancy with high risk of recurrence, multi‑organ failure, other significant gastrointestinal diseases (e.g., bleeding peptic ulcer, diverticulitis, chronic hepatitis), ongoing sepsis, and unstable alcohol or substance use disorder (with exceptions permitted when documentation shows ≥3 months of stability).
Contraindications and exclusion criteria are summarized in policy text, but a comprehensive, itemized list is not provided in every excerpt of the document. Refer to the full contraindications section and coding lists for the specific diagnoses and codes that are considered exclusions under this policy.
Pre-Transplant Evaluation Requirements
Perform comprehensive cardiac, hepatic, renal, infectious, psychiatric/substance use and HIV evaluations
Pre‑transplant assessment must include evaluation of cardiac, hepatic, renal, infectious, psychiatric/substance use and HIV status; for combined liver‑intestinal candidates, measured GFR is recommended to assess renal function.
- Cardiac: ejection fraction ≥40% per selection criteria.
- Hepatic: bilirubin and clinical signs of liver disease; combined candidates may be considered when liver disease necessitates liver transplant.
- Renal: creatinine clearance >50 ml/min/kg; for combined transplants, measured GFR recommended.
- Infectious and HIV: ensure absence of untreated infection and controlled HIV (CD4 >200 for >6 months, undetectable viral load).
- Psychiatric/substance use: documentation of stability and ability to comply with treatment.
Include clinical function, labs, endoscopy/biopsy, and immunologic testing in evaluation
Cited pre‑transplant evaluations in outcome studies included assessment of clinical function, laboratory values, serial endoscopy with biopsy for graft monitoring, and immunologic testing (including DSA screening) as part of candidate workup and post‑transplant surveillance.
- Graft monitoring in studies used clinical function, labs, and serial endoscopy with biopsy.
- Immunologic testing and DSA surveillance were performed at serial intervals in cited cohorts.
Transplant Center Requirements
Transplantation considered necessary when transplant center protocol eligibility criteria are met
Aetna considers transplantation medically necessary when the member meets the transplanting institution’s protocol eligibility criteria; if no protocol is provided, the Aetna selection criteria must be documented and met.
- Submit the transplant center’s protocol eligibility criteria when available to support medical necessity.
Center experience may be provided but must be supplemented by protocol/selection criteria
Center experience is not specified in this excerpt; referenced studies describe single‑center experiences and protocols that inform outcomes and selection practices.
- Clinical and outcome descriptions from single‑center series may be included to support medical necessity but are not substitute for documented candidate criteria.
Post-Transplant Follow-up and Monitoring
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.