ModifiedAmbetter NevadaPolicy CP.MP.58

Clinical Policy: Intestinal and Multivisceral Transplant

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.58 alerts

Get alerted when Policy CP.MP.58 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity criteria and coding guidance for isolated intestinal, combined intestine-liver, and multivisceral transplantation for pediatric and adult members/enrollees with irreversible intestinal failure.

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.

ModifiedAmbetter NevadaPolicy CP.MP.58

Clinical Policy: Intestinal and Multivisceral Transplant

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.58 alerts

Get alerted when Policy CP.MP.58 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Nevada

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeRevisions to contraindications and clarifications to indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation demonstrating one listed indication for transplant and absence of any contraindication.

SourceLink

POLICY UPDATE CHANGES

Updated contraindications to include specific GFR threshold, HIV with detectable viral load conditions, stroke/ACS/MI timing, septic shock, progressive cognitive impairment, and clarified substance use policy.

Expanded and clarified indications related to TPN-induced liver injury and hospitalization requirements for recurrent line infections.

Adjusted GFR contraindication value multiple times (documented changes between <30 and <40 mL/min/1.73m2).

3Procedure types

10+Contraindications listed

200+Codes referenced

Pediatric & adultPopulations covered

Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when ALL of the following are met: member/enrollee has irreversible intestinal failure, meets at least one indication in II.A, and has none of the contraindications in II.B.

Overall coverage logic: Member/enrollee must have irreversible intestinal failure and meet at least one indication in II.A and have none of the contraindications in II.B.

From Policy/Criteria (sections I–II)

The policy has undergone multiple revisions between 2021 and 2025 that updated contraindications and clarified criteria language. Notable changes include replacement and rewording of prior contraindications (for example, removing wording such as 'severely limited functional status with poor rehabilitation potential' and consolidating nonadherence/psychological exclusions into "Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support.") and additions of specific items such as a GFR restriction, HIV criteria, recent vascular events, septic shock, and progressive cognitive impairment.

Revision history documents that the GFR threshold in Criteria II.B.3 was edited (values adjusted in revisions) and other clarifications were added to candidate and contraindication language. The revision log entries and approval dates are summarized in the document revision notes and should be consulted for exact revision dates and wording.

Coverage under this clinical policy is subject to the member's benefit documents, contract terms, and any applicable legal or regulatory requirements. The policy may be updated, changed, or withdrawn by the Health Plan and the posted date may not reflect the plan-determined effective date.

Providers must follow the Health Plan's administrative procedures (including prior authorization processes where applicable) and adhere to any state Medicaid provisions that take precedence over this policy for Medicaid members. This clinical policy does not replace clinical judgment and does not itself constitute a guarantee of coverage.

Clinical guidelines caution that intestinal transplantation should not be performed solely because of continued dependence on total parenteral nutrition (TPN). The American Society of Transplantation specifically recommends transplantation for pediatric TPN‑dependent patients only when they have or are likely to develop life‑threatening TPN‑related complications (for example, liver disease, recurrent sepsis, or threatened loss of central venous access).

Referral for transplant consideration is appropriate for patients with irreversible intestinal failure who are expected to die prematurely on TPN or who meet guideline-based criteria for life‑threatening TPN complications, rather than for TPN dependence alone.

Candidate Indications for Transplant

Candidate indications

Candidate indications for intestinal or multivisceral transplant include, but are not limited to; any one of the following satisfies II.A:

Failure of total parenteral nutrition (TPN) as indicated by one or more of: (a) impending or overt TPN‑induced liver injury (elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro‑esophageal varices, coagulopathy, stomal bleeding, or hepatic fibrosis/cirrhosis); (b) thrombosis of two or more central veins (jugular, subclavian, femoral); (c) two or more episodes per year of systemic sepsis due to line infection requiring hospitalization; (d) one episode of septic shock, acute respiratory distress syndrome (ARDS), and/or line‑related fungemia; (e) frequent severe dehydration despite IV fluid supplementation in addition to TPN; (f) other complications leading to loss of vascular access.

II.A.1 from policy text

High risk of death if transplant is not performed.

II.A.2 from policy text

Severe short bowel syndrome defined by gastrostomy, duodenostomy, and/or residual small bowel <10 cm in infants and <20 cm in adults.<10 cm (infants); <20 cm (adults)

Contraindications and Denial Conditions

Presence of any of the following contraindications generally precludes coverage unless otherwise specified: malignancy with high risk of recurrence or death related to cancer; other severe uncontrolled medical condition expected to limit survival after transplant; glomerular filtration rate <40 mL/min/1.73 m2 unless being considered for multi‑organ transplant; HIV infection with detectable viral load unless the candidate meets all specified criteria (CD4 >200 cells/mm3, absence of active AIDS‑defining opportunistic infection or malignancy, and on effective antiretroviral therapy); and septic shock.

Additional contraindications include progressive cognitive impairment; recent vascular events such as stroke, acute coronary syndrome, or myocardial infarction within 30 days; chronic uncontrolled infection with highly virulent or resistant organisms that is not controlled pre‑transplant; inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support; and active substance use or dependence (including current tobacco/vaping or IV drug use, or marijuana use unless prescribed) without convincing evidence of risk‑reduction behaviors, except in urgent circumstances where documented commitment to reducing risk may be considered.

Pretransplant Evaluation and Documentation Requirements

Denial Risk

Denial triggers — listed contraindications

Denial triggers — transplant evaluation must document absence of contraindications. Do not proceed if any listed contraindication is present.
Common denial triggers include uncontrolled malignancy with high risk of recurrence, severe uncontrolled comorbidity expected to limit post‑transplant survival, GFR < 40 mL/min/1.73 m2 (unless multi‑organ transplant planned), detectable HIV viral load (unless CD4 >200, no active AIDS‑defining infection/malignancy, and on effective ART), septic shock, progressive cognitive impairment, recent stroke/acute coronary syndrome/MI within 30 days, uncontrolled chronic infection with highly virulent or resistant organisms, inability to adhere to required regimen even with caregiver support, and active substance use/dependence (including current tobacco/vaping/marijuana use not prescribed, or IV drug use) without convincing risk‑reduction.

Malignancy with high risk of recurrence or death
Other severe uncontrolled medical condition expected to limit survival after transplant
GFR < 40 mL/min/1.73 m2 unless being considered for multi‑organ transplant
HIV with detectable viral load (acceptable only if CD4 >200, no active AIDS‑defining infection/malignancy, and on effective ART)
Septic shock
Progressive cognitive impairment
Stroke, acute coronary syndrome, or MI within 30 days

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Obtain prior authorization and submit clinical criteria with requests

Prior authorization is required for the listed intestinal and multivisceral transplant procedures and associated CPT/HCPCS codes; requests must include clinical criteria demonstrating that Section II medical necessity criteria are met.

Include supporting clinical documentation with the prior authorization request showing the indication and absence of contraindications per Section II.
Submit requests using the CPT and HCPCS codes referenced in the policy (e.g., 44135, 44136, S2053, S2054, S2152).

Prior Authorization

Follow Health Plan effective date and prior authorization process

This clinical policy is effective as of the Health Plan–determined date and prior authorization requirements follow the Health Plan's administrative procedures; providers should follow the Health Plan's prior authorization process and timelines.

The posting date may not be the effective date; follow the Health Plan’s stated effective date and administrative prior authorization instructions.

Procedure and Billing Codes

Covered CPT Codes (intestine)CPTCovered

44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; from living donor.
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 anastomosis, each.
44721	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each.

Covered CPT Codes (liver)CPTCovered

47135	Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age.
47143	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; without trisegment or lobe split.
47144	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with trisegment split.
47145	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with lobe split.
47146	Backbench reconstruction of donor liver graft prior to allotransplantation; venous anastomosis, each.
47147	Backbench reconstruction of donor liver graft prior to allotransplantation; arterial anastomosis, each.

HCPCS CodesHCPCSCovered

S2053	Transplantation of small intestine and liver allografts.
S2054	Transplantation of multivisceral organs.
S2055	Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor.
S2152	Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and posttransplant care in the global definition.

Residual small bowel length thresholds for severe short bowel syndrome (SBS)

Infants — residual small bowel length<10 cm

Adults — residual small bowel length<20 cm

Contextual SBS thresholdSBS often considered when ~<200 cm of small bowel remains (clinical background)

Glomerular filtration rate (GFR) contraindication threshold

GFR contraindication thresholdGlomerular filtration rate <40 mL/min/1.73m2 (unless being considered for multi-organ transplant)

Policy revision noteGFR value has been revised historically (document notes prior use of <30 mL/min/1.73m2)

Background and Clinical Context

Intestinal failure is the loss of small‑bowel absorptive capacity resulting from primary gastrointestinal disease or from surgical short bowel syndrome; it may lead to dependence on parenteral nutrition when enteral intake cannot meet nutritional and fluid needs.

Clinical course varies by etiology and age: short bowel syndrome often follows extensive small bowel resection and can present with malabsorption, dehydration, and dependence on TPN. In children, common causes include congenital conditions (e.g., small bowel atresia, gastroschisis, aganglionosis) and necrotizing enterocolitis; in adults, causes include mesenteric ischemia, Crohn's disease, trauma, and tumors. Progressive complications of intestinal failure include TPN‑associated liver injury, recurrent central line infections, loss of vascular access, and risk of premature mortality without transplant.

Key Definitions

Definition — Short bowel syndrome (SBS)

Definition (SBS)Short bowel syndrome (SBS) = loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome

Clinical characterizationTypical small intestine length varies widely (3–8 meters); SBS often occurs when approximately <200 cm of small bowel remain

Relevance to transplantSBS may be an indication for intestinal transplantation when severe and meeting residual length thresholds

Definition — Multivisceral transplant scope (which organs included/excluded)

Included organsMultivisceral transplantation may include stomach, duodenum, pancreas, liver, small intestine, and large intestine

Optional exclusionA modified multivisceral graft may exclude the liver if the recipient's liver is normal

Post-Transplant Services and Coverage

Pre- and post-transplant care included in global definition per referenced HCPCS description

HCPCS S2152 global definitionS2152 includes procurement, transplantation, related complications, drugs, supplies, hospitalization with outpatient follow-up, and the number of days of pre- and post-transplant care in the global definition

Pre-transplant care includedPre-transplant care days are included in the HCPCS global definition referenced

Post-transplant care includedPost-transplant care days are included in the HCPCS global definition referenced

Post-transplant services covered per member's plan and applicable NCD/LCD guidance

Plan and CMS guidance determine coveragePost-transplant services are covered according to the member's plan terms and applicable Medicare NCDs/LCDs; review applicable CMS determinations prior to application

Center and Program Requirements

Note

No explicit center accreditation or volume requirements specified — refer to Health Plan/CMS

No explicit center accreditation or minimum volume requirements are specified in these sections of the clinical policy; providers should comply with Health Plan and CMS facility accreditation and compliance requirements.

Refer to the Health Plan and CMS for any facility-level accreditation, credentialing, or volume standards that may apply.
This policy does not list specific center‑level requirements in the document sections cited.

Policy Summary

PayerAmbetter Nevada

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeRevisions to contraindications and clarifications to indications

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit clinical documentation demonstrating one listed indication for transplant and absence of any contraindication.

SourceLink

On This Page

II.A.3 and thresholds from policy

Frequent hospitalizations for complications directly related to intestinal failure (e.g., opioid dependency for pain management, or pseudo‑obstruction).

II.A.4 from policy text

Significant hepatic cirrhosis with portomesenteric thrombosis: Significant hepatic cirrhosis associated with diffuse portomesenteric thrombosis.

II.A.5 from policy text

Pediatric-specific common indications (examples): Small bowel atresia; gastroschisis; aganglionosis (Hirschsprung's disease); necrotizing enterocolitis; mesenteric ischemia; intestinal pseudo‑obstruction; microvillus inclusion disease.

Common pediatric indications listed in policy

Adult-specific common indications (examples): Short gut syndrome; mesenteric ischemia following thrombosis/embolism/volvulus/trauma; Crohn's disease; small bowel tumors; small bowel secretory disorders.

Common adult indications listed in policy

Chronic infection with highly virulent/resistant microbes poorly controlled pre‑transplant

Inability to adhere to post‑transplant regimen even with caregiver support

Active substance use/dependence (including current tobacco/vaping/marijuana use not prescribed, or IV drug use) without documented risk‑reduction

Denial Risk

General denial risk

General denial risk: incomplete or missing documentation of the specific transplant indication, failure of TPN criteria or other listed indications, or absence of explicit assessment of the contraindications above may lead to denial of coverage for transplant services.

Missing documentation of one of the required indications (e.g., TPN failure criteria, severe short bowel, frequent hospitalizations for intestinal‑failure complications, high risk of death without transplant)
No documented assessment of renal function (GFR) relative to the < 40 mL/min/1.73 m2 threshold
No documentation of HIV viral load, CD4 count, or ART status when applicable
No evidence of substance‑use risk‑reduction or serial testing when active use is a concern

Documentation Required

Required clinical documentation

Required clinical documentation: evaluators must document the specific indication for transplant and supporting clinical evidence, and explicitly assess for each contraindication. Include objective data for renal function, HIV status and treatment, malignancy history, infection status, recent cardiovascular/cerebrovascular events, cognitive status, and adherence/substance use evaluation.

Clear statement of which indication is met and supporting notes (e.g., TPN failure with details of bilirubin/liver enzymes/portal hypertension; number of central vein thromboses; sepsis episodes; residual bowel length for short bowel syndrome)
Renal function: documented GFR or eGFR value and interpretation relative to 40 mL/min/1.73 m2
HIV: viral load, CD4 count, documentation of effective ART and absence of active AIDS‑defining conditions when applicable
Malignancy: oncologic history, staging, treatment status, and assessment of recurrence risk
Infection: cultures, infectious disease consult notes, evidence of control for chronic/resistant organisms
Cardiovascular/cerebrovascular: dates and details of any stroke, acute coronary syndrome, or MI
Cognitive and psychosocial assessment: ability to adhere, caregiver support documentation
Substance use: screening results, treatment/abstinence documentation, and serial urine/blood testing when used to verify abstinence

Note

Medicare documentation alignment

Medicare alignment: evaluation workup and documentation should align with CMS National Coverage Determinations and applicable Medicare guidance (including pretransplant assessment of indications, contraindications, renal function thresholds, and HIV criteria). Review CMS NCDs and cited clinical literature prior to authorization submission to ensure Medicare‑consistent documentation.

Follow CMS NCD guidance for transplant indications and contraindications where applicable
Include the same objective measures and thresholds used in Medicare determinations (e.g., GFR thresholds, HIV viral load/CD4 parameters)
Attach relevant consults, imaging, labs, and specialty notes to mirror Medicare documentation expectations

Step Therapy

Step therapy / Preauthorization

Step therapy / preauthorization considerations: confirm any required prior authorization and complete the recommended pretransplant workup before submission. Missing stepwise documentation of failed conservative therapies (e.g., TPN management attempts) or lack of required testing may prompt step‑down requirements or denial.

Verify and obtain prior authorization per payer rules before listing or transplant scheduling
Document attempts and failure of medical/conservative management (e.g., TPN complications, vascular access loss, recurrent line infections) as applicable to indication
Ensure completion of recommended pretransplant evaluations (labs, imaging, specialist consultations) and include in the authorization packet

Step Therapy

No step therapy provisions specified

No step therapy provisions are specified in this policy; coverage is determined based on meeting the medical necessity criteria outlined in Section II.

Do not apply step therapy requirements — coverage depends on meeting listed indications and absence of contraindications.

Step Therapy

No step therapy requirements in this policy

This document does not specify any step therapy requirements in its sections; providers should base coverage decisions on the medical necessity criteria provided.

Use the policy’s Section II criteria rather than step therapy pathways when evaluating candidates.

Denial Risk

Denial triggers: listed contraindications may lead to denial

Requests may be denied if the member/enrollee has any listed contraindication, including malignancy with high risk of recurrence, other severe uncontrolled medical conditions limiting survival, GFR <40 mL/min/1.73m2 (unless multi‑organ transplant), uncontrolled HIV with detectable viral load not meeting specified criteria, septic shock, progressive cognitive impairment, recent stroke/ACS/MI within 30 days, chronic uncontrolled infection with resistant organisms, inability to adhere to required regimen, or active substance use without evidence of risk reduction.

GFR threshold for denial: <40 mL/min/1.73m2 unless multi‑organ transplant is planned.
HIV with detectable viral load is a contraindication unless CD4>200, no active AIDS‑defining infection/malignancy, and on effective ART.

Denial Risk

Coverage subject to plan terms, exclusions, and administrative policies

Coverage decisions are subject to the member's coverage documents, state/federal requirements, and applicable Health Plan administrative policies; failure to meet those terms, conditions, exclusions, or limitations may result in denial.

Verify member eligibility, benefits, and any plan exclusions or limitations prior to proceeding.
State Medicaid provisions take precedence where conflicts exist.

Documentation Required

Review NCDs/LCDs and ensure documentation supports Medicare determinations

For Medicare members/enrollees, review all applicable Medicare NCDs, LCDs, and Medicare Coverage Articles prior to applying the policy criteria and ensure submitted documentation supports compliance with those determinations.

Confirm that documentation aligns with relevant Medicare coverage guidance available on the CMS website.
Adjust submissions to meet NCD/LCD requirements for Medicare members as needed.

Evaluation implicationCandidates with GFR below threshold should be evaluated for multi-organ transplant eligibility rather than isolated intestinal transplant

Occasional additionA kidney may occasionally be included if the recipient has end-stage renal disease

Definition — Intestinal and multivisceral transplantation (surgical replacement description)

Surgical descriptionIntestinal transplantation = surgical replacement of the small intestine alone or as part of a multivisceral graft

Indications describedUsed for patients with intestinal failure, intestinal-failure–associated liver disease, diffuse portomesenteric thrombosis, or other listed indications

Graft composition noteMay be performed as isolated intestine, combined intestine-liver, or broader multivisceral grafts depending on clinical needs

Administrative reminder

Coverage decisions are subject to all terms, conditions, exclusions, and limitations of the coverage documents and Health Plan administrative policies

Medicare membersFor Medicare members, review all applicable NCDs, LCDs, and Medicare Coverage Articles before applying this policy's criteria