ModifiedAmbetter NevadaPolicy CP.MP.58

Intestinal and Multivisceral Transplant

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This policy governs medical-necessity review for isolated intestinal, combined intestinal-liver, multivisceral, and retransplantation procedures for pediatric and adult members with irreversible intestinal failure. Coverage requires qualifying clinical indications and no listed contraindications.

Policy Summary

PayerAmbetter Nevada

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeModified

Effective DateOct 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionDocument at least one qualifying transplant indication and confirm that no listed contraindication is present.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review added criteria for large desmoid or other intra-abdominal tumors and congenital secretory diarrheal disorders.

The 2026 annual review added medical-necessity criteria for retransplantation.

The 2026 annual review added CPT code 44137 and CPT code 48554 to the coding references.

The policy clarified criteria in Section II.A.1, including TPN-induced liver injury, use of the term stomal, hospitalization requirements, separation of criteria points, and additional language in Criterion II.A.1.d.

The policy changed the terminology from post-mesenteric to portomesenteric and revised the GFR threshold in Criterion II.B.3 from less than 30 to less than 40 mL/min/1.73 m².

The policy removed information regarding placement on the heart transplant waiting list, the criterion for other gastrointestinal diseases, the criterion for acute liver failure or cirrhosis, and the contraindication based on absence of an adequate support system.

The policy added criteria under Sections II.A.6-II.A.7 for large desmoid tumors and added retransplantation criteria under Section III.

The policy added CPT codes 44137 and 48554 to the reviewed coding set.

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ModifiedAmbetter NevadaPolicy CP.MP.58

Intestinal and Multivisceral Transplant

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

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Policy Summary

PayerAmbetter Nevada

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeModified

Effective DateOct 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionDocument at least one qualifying transplant indication and confirm that no listed contraindication is present.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review added criteria for large desmoid or other intra-abdominal tumors and congenital secretory diarrheal disorders.

The 2026 annual review added medical-necessity criteria for retransplantation.

The 2026 annual review added CPT code 44137 and CPT code 48554 to the coding references.

The policy changed the terminology from post-mesenteric to portomesenteric and revised the GFR threshold in Criterion II.B.3 from less than 30 to less than 40 mL/min/1.73 m².

The policy added criteria under Sections II.A.6-II.A.7 for large desmoid tumors and added retransplantation criteria under Section III.

The policy added CPT codes 44137 and 48554 to the reviewed coding set.

Coverage Criteria

Transplantation procedure selection

The transplant procedure must be aligned with the member’s intestinal failure and associated disease.

ONE of the following procedure types

Isolated intestinal transplantation for isolated intestinal failure without liver disease.
Combined intestinal and liver transplantation for intestinal failure with end-stage liver disease.
Multivisceral transplantation for intestinal failure with gastrointestinal motility disorders, including chronic idiopathic intestinal pseudo-obstruction, visceral myopathy, visceral neuropathy, total intestinal aganglionosis, some mitochondrial respiratory chain disorders affecting gastrointestinal motor function, or extensive mesenteric thrombosis.

Primary transplant indications

Coverage requires at least one of the following primary transplant indications:

ONE of the following indications

Failure of total parenteral nutrition (TPN), demonstrated by ONE or more of the following
- Impending or overt liver failure due to TPN-induced liver injury, indicated by elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro-esophageal varices, coagulopathy, stomal bleeding, or hepatic fibrosis/cirrhosis.
- Thrombosis of two or more central veins, including jugular, subclavian, and femoral veins.
- Two or more episodes of systemic sepsis due to line infection per year requiring hospitalization.
- One episode of septic shock, acute respiratory distress syndrome, and/or line-related fungemia.
- Frequent episodes of severe dehydration despite IV fluid supplementation in addition to TPN.

Indications and contraindications

Procedure criteria require at least one primary transplant indication and none of the applicable contraindications.

ALL of the following

Meets at least one primary transplant indication listed above.
Has NONE of the following contraindications
- 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/1.73m², unless being considered for multi-organ transplant.
- HIV infection with detectable viral load, unless CD4 cell count is >200 cells/mm³, there is no active AIDS-defining opportunistic infection or malignancy, and the member is currently receiving effective antiretroviral therapy.

Retransplantation criteria

A second transplant may be considered medically necessary when all primary transplantation criteria have been met and one of the following graft-failure indications applies.

ALL of the following

All primary criteria for transplantation are met.
ONE of the following graft-failure indications
- Graft failure following a primary small bowel, small bowel-liver, or multivisceral transplantation due to technical complications or acute rejection.
- Graft failure attributable to chronic rejection or recurrence of the primary disease.

Active substance use or dependence is a contraindication, including current tobacco use, vaping, marijuana use unless prescribed by a licensed practitioner, or intravenous drug use without convincing evidence of risk-reduction behaviors. If urgent transplant timelines are present, a commitment to reducing behaviors is acceptable. Serial blood and urine testing may be used to verify abstinence from substances of concern.

Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support, is a contraindication.

Coding References and Clinical Thresholds

CPT CodesCPT

44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; 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 anastomosis, each.
44721	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each.
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, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein.
47144	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split.
47145	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with trisegment split of whole liver graft into two partial liver grafts.

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HCPCS CodesHCPCS

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 post-transplant care in the global definition.

Added CPT CodesCPT

44137
48554

Residual Small Bowel Length

InfantsResidual small bowel length less than 10 cm

AdultsResidual small bowel length less than 20 cm

Related indicationSevere short bowel syndrome, including gastrostomy, duodenostomy, and/or the specified residual small bowel length

Glomerular Filtration Rate

Contraindication thresholdGlomerular filtration rate less than 40 mL/min/1.73 m²

ExceptionThe threshold does not apply when multi-organ transplantation is being considered

Provider Review and Denial Risks

Documentation Required

Indication and Contraindication Review

Confirm that the member/enrollee has at least one qualifying indication for intestinal or multivisceral transplant and none of the listed contraindications before proceeding with review.

Qualifying indications include severe short bowel syndrome; frequent hospitalizations for complications directly related to intestinal failure; significant hepatic cirrhosis associated with diffuse portomesenteric thrombosis; large desmoid or other intra-abdominal tumors with reasonable expectation of posttransplant cure; or congenital secretory diarrheal disorders.
Document the indication and evaluate the complete contraindication list.

Denial Risk

Contraindications and Denial Risks

Do not approve when the member has a malignancy with high risk of recurrence or cancer-related death, or another severe uncontrolled medical condition expected to limit survival after transplant.

Policy Background

Intestinal failure is loss of small-bowel absorptive capacity caused by severe primary gastrointestinal disease or surgically induced short bowel syndrome. Short bowel syndrome occurs when approximately less than 200 cm of small bowel remains. Multivisceral transplantation may include the stomach, duodenum, pancreas, liver, small intestine, and large intestine; a modified procedure may exclude the liver when liver function is normal, and a kidney may occasionally be included for end-stage renal disease.

Key Definitions

Intestinal Failure

Core definitionLoss of absorptive capacity of the small bowel

Primary disease causeSevere primary gastrointestinal disease

Surgical causeSurgically induced short bowel syndrome

Short Bowel Syndrome

DefinitionA condition in which approximately less than 200 cm of small bowel remains

Approximate thresholdLess than 200 cm of remaining small bowel

Clinical relationshipShort bowel syndrome is a surgically related cause of intestinal failure

Transplant Candidate Requirements

Intestinal and Multivisceral Transplant Candidate Criteria

Candidates must meet all of the following requirements.

Candidate eligibility: The member is a pediatric or adult candidate with irreversible intestinal failure, at least one qualifying transplant indication, and no listed contraindication.

Retransplantation Candidate Criteria

Retransplant candidates must meet all primary transplant criteria and one additional graft-failure indication.

Retransplant candidate criteria: The member meets all primary transplantation criteria and has graft failure from technical complications, acute rejection, chronic rejection, or recurrence of the primary disease.

Transplant Contraindications

Transplantation is contraindicated for malignancy with a high risk of recurrence or cancer-related death; another severe, uncontrolled medical condition expected to limit post-transplant survival; GFR less than 40 mL/min/1.73 m² unless multi-organ transplantation is being considered; or HIV infection with a detectable viral load unless the member has a CD4 count greater than 200 cells/mm³, no active AIDS-defining opportunistic infection or malignancy, and current effective antiretroviral therapy. Other contraindications are septic shock; progressive cognitive impairment; stroke, acute coronary syndrome, or myocardial infarction within 30 days, excluding demand ischemia; and chronic infection with highly virulent or resistant microbes that is poorly controlled before transplant. Contraindications also include inability to adhere to the transplant-preservation regimen even with caregiver support and disqualifying active substance use or dependence involving tobacco, vaping, marijuana unless prescribed, or intravenous drug use without convincing evidence of risk-reduction behavior, subject to the urgent-transplant-timeline exception.