EVALUATION REQUIREMENTS — Document intestinal failure severity, TPN complications, vascular access, sepsis, liver and other organ function

Pre‑transplant evaluation must document the severity of intestinal failure, including measurements of residual small bowel length, history and complications of total parenteral nutrition (TPN), vascular access status (including central vein thromboses and loss of access), history of sepsis/line infections and related hospitalizations, liver disease staging, and assessment of other organ function such as renal GFR.

• Residual small bowel length (report <10 cm in infants; <20 cm in adults when applicable).
• TPN complications: evidence of TPN‑induced liver injury, recurrent line infections, thrombosis of central veins, loss of vascular access.
• Sepsis history: number of systemic sepsis episodes requiring hospitalization, episodes of septic shock/ARDS/line‑related fungemia.
• Vascular access status: thrombosis of two or more central veins or other loss of access events.
• Liver disease staging and portal/mesenteric thrombosis assessment.
• Renal function assessment (GFR) and other organ evaluations.

EVALUATION REQUIREMENTS — Use referenced clinical guidelines and literature for evaluation and indications

The policy explicitly references clinical guidance and peer‑reviewed literature to inform pre‑transplant evaluation and indications; providers should use sources such as UpToDate, ESPEN guidelines, and cited transplant literature when performing workup and determining candidacy.

• UpToDate overview of intestinal and multivisceral transplantation (cited).
• ESPEN guidelines on chronic intestinal failure (cited).
• Peer‑reviewed transplant literature and society position statements (e.g., AST, British Society of Gastroenterology).

Prior authorization required — demonstrate medical necessity per policy criteria

Prior authorization is required and must demonstrate the member meets the policy medical necessity criteria for isolated intestinal, combined intestinal‑liver, or multivisceral transplantation as described in Section II.

• Include evidence that one qualifying indication (II.A) is met and that no contraindications (II.B) are present.
• Reference applicable CPT/HCPCS codes when submitting authorization (see coding section).

Review Medicare/Medicaid determinations before authorization

For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Coverage Articles prior to applying this policy’s criteria and submitting authorization requests.

• Refer to the CMS website and applicable NCD/LCDs to ensure consistency with Medicare guidance.

Step therapy — not applicable for transplant candidacy

Step therapy is not applicable to transplant candidacy in this policy; no step therapy sequence is specified as a prerequisite to authorization for intestinal or multivisceral transplant.

Required documentation — demonstrate one qualifying indication and absence of contraindications

Include documentation demonstrating medical necessity by showing one qualifying indication (per II.A) and that no contraindications (per II.B) exist; submit clinic notes, hospital records, imaging, laboratory data, operative reports, and relevant procedure codes as applicable.

• Evidence of TPN failure (e.g., labs, imaging for TPN‑induced liver injury, documentation of central vein thromboses, sepsis hospitalizations).
• Measured residual bowel length when claiming severe short bowel.
• Liver disease staging and portal/mesenteric thrombosis documentation.
• Relevant CPT/HCPCS codes to accompany claims/authorization.

Provider documentation and compliance — follow coverage documents and legal requirements

Providers must follow this clinical policy and any applicable coverage documents and legal/regulatory requirements when submitting claims and seeking authorization; professional judgment remains the responsibility of the treating provider.

• Adhere to evidence of coverage, provider agreements, and state/federal regulations when submitting requests.

Triggers for denial — failure to meet indications or presence of contraindications

Requests may be denied if the member does not meet any qualifying indication (II.A) or if any listed contraindication (II.B) is present — examples include failure to document TPN failure criteria, severe short bowel thresholds, GFR below the contraindication threshold, active uncontrolled infection, or inability to adhere to the required regimen.

• Denial triggers include lack of evidence for TPN failure, residual bowel length not meeting thresholds, documented contraindications such as malignancy with high recurrence risk, GFR <40 mL/min/1.73m2 (unless multi‑organ transplant), septic shock, or active substance use without risk‑reduction evidence.

Coverage conditions and legal precedence — subject to plan terms and applicable law

Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions, and limitations of the member’s coverage documents and to applicable state and federal requirements; where conflicts with state Medicaid provisions occur, state Medicaid rules take precedence.

CENTER REQUIREMENTS — guideline‑based recommendations; no explicit payer accreditation stated

The policy references professional guideline recommendations and specialist review for center‑level considerations but does not specify explicit payer center accreditation or certification requirements within this document.

• Follow professional society guidance and specialist consultation for program structure and case selection.

CENTER REQUIREMENTS — follow Medicare NCD/LCD and Health Plan certification/regulatory requirements

For center certification and regulatory compliance, refer to and align with applicable Medicare NCDs/LCDs and the Health Plan’s requirements for facility certification and relevant state regulatory rules.

• Review CMS NCD 260.5 and any relevant LCDs/Coverage Articles when applicable to Medicare members.