CurrentBlue Cross Blue Shield - MassachusettsPolicy 631

Small bowel (intestinal) transplant

Clinical coverage and authorization guidance for small bowel (intestinal) transplantation for Blue Cross Blue Shield of Massachusetts members, including indications, exclusions, and coding; applies to commercial members and inpatient settings.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicySmall bowel (intestinal) transplant

Policy CodePolicy 631

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization for all inpatient small bowel transplant procedures and submit a transplant team statement when recent malignancy exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97intestinal transplants performed in the U.S. in 2024

174patients on the intestinal transplant waiting list

3policy sections in table of contents

34total references listed (partial)

OPTN/HOPE Actincludes OPTN/HOPE Act reference

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Small Bowel Transplant

Medically Necessary 20 Cadaveric small bowel transplant (adults and pediatrics)

Covered when ALL of the following are met

Intestinal failure (loss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance)

TPN dependency: Established long-term dependency on total parenteral nutrition (TPN)

TPN complications: Developing or have developed severe complications due to TPN

Complications include catheter-related mechanical problems, infections, hepatobiliary disease, and metabolic bone disease

Medically Necessary 20 Living donor small bowel transplant

Covered when ALL of the following are met (living donor 20 restricted)

Cadaveric unavailable: Cadaveric intestine is NOT available for transplantation

Living donor transplant is allowed only when cadaveric organ not available

Meets cadaveric criteria: Patient meets the criteria noted above for cadaveric intestinal transplant

Medically Necessary 20 Retransplantation

Failed primary transplant: Small bowel retransplant may be MEDICALLY NECESSARY after a failed primary small bowel transplant

Applies when no contraindications to retransplantation

Small bowel transplant is not covered when any of the following are present: known current malignancy, including metastatic cancer; recent malignancy with high risk of recurrence; untreated systemic infection that makes immunosuppression unsafe (including chronic infection); other irreversible end‑stage disease not attributed to intestinal failure; a history of cancer with a moderate risk of recurrence; systemic disease that could be exacerbated by immunosuppression; or psychosocial conditions or chemical dependency

Small bowel transplant in adult patients with intestinal failure who are able to tolerate total parenteral nutrition (TPN) is considered investigational (not covered).

Use of a living donor for small bowel transplantation is investigational (not covered) in all situations except when a cadaveric intestine is not available and the patient otherwise meets the criteria for cadaveric intestinal transplant.

The policy text does not reproduce every exclusion or federal limitation in full; it references external regulatory guidance. In particular, the Centers for Medicare & Medicaid Services National Coverage Determination (NCD) for Intestinal and Multivisceral Transplantation (260.5) is cited and contains federal coverage limitations that may apply to member claims and authorization decisions.

To restate: outside the limited exception where cadaveric intestine is unavailable and the patient meets cadaveric criteria, living donor small bowel transplant is investigational (not covered).

Candidate Selection and Eligibility

Candidate selection

Candidate selection centers on intestinal failure with TPN dependence and TPN-related complications; other clinical factors and comorbidities that affect posttransplant outcomes must be considered.

Intestinal failure: Patient has intestinal failure as defined by inadequate absorption and inability to maintain nutrition without TPN

Long-term TPN dependence: Established long-term dependency on TPN

TPN complications present: Patient developing or with severe complications from TPN (catheter-related mechanical problems, infections, hepatobiliary disease, metabolic bone disease)

Contraindications

Contraindications that preclude coverage include: known current malignancy, including metastatic disease; recent malignancy with high risk of recurrence; untreated systemic infection that makes immunosuppression unsafe; and other irreversible end‑stage organ dysfunction not attributed to intestinal failure. Additional factors that may contraindicate transplant include history of cancer with moderate recurrence risk, systemic diseases worsened by immunosuppression, and psychosocial or chemical dependency issues that impede adherence.

Provider Actions, Authorization, and Documentation

Prior Authorization
Prior Authorization Required
Precertification/preauthorization is required for all products when the intestinal transplant procedure is performed inpatient. For outpatient settings, prior authorization requirements depend on product type and local plan rules; Commercial Managed Care (HMO and POS) and Commercial PPO/Indemnity treat this procedure as inpatient for coverage determination. Providers should confirm outpatient prior authorization requirements with the member's plan.
Inpatient: precertification/preauthorization IS REQUIRED for all products.
Outpatient: check product-specific rules; Commercial Managed Care (HMO and POS) and Commercial PPO/Indemnity — procedure considered inpatient for coverage.

Documentation Required
CMS NCD and OPTN/HOPE Act Alignment
The policy references the CMS National Coverage Determination (NCD 260.5) for Intestinal and Multivisceral Transplantation and OPTN policies (including HOPE Act materials). Providers must be aware that federal coverage criteria and OPTN/UNOS/HOPE Act requirements may influence medical necessity determination, documentation expectations, and donor/recipient eligibility. Align preauthorization and documentation submissions with CMS NCD criteria and applicable OPTN policies.

Coding

CPT CodesCPT

44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; from living donor.

ICD-10-PCS Procedure CodesICD-10

0DY80Z0	Transplantation of Small Intestine, Allogeneic, Open Approach.
0DY80Z1	Transplantation of Small Intestine, Syngeneic, Open Approach.

Definitions

Intestinal failure

DefinitionLoss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance

Clinical implicationMay require long-term total parenteral nutrition (TPN)

Coverage contextMeets primary indication for cadaveric small bowel transplant when combined with long-term TPN dependence and severe TPN-related complications

Short bowel syndrome

DefinitionCondition in which the absorbing surface of the small intestine is inadequate due to extensive disease or surgical resection

Clinical spectrumRanges from isolated micronutrient malabsorption to complete intestinal failure (insufficient macronutrient/water/electrolyte absorption)

Post-Transplant Care and Surveillance

Post-transplant immunosuppression and surveillance

DurationLifelong immunosuppression is required after intestinal transplant

Major risksHigh risk of infection and treatment-related morbidity following transplant

Clinical balanceRisks weighed against avoidance of long-term TPN complications and potential to obviate combined liver/small bowel transplant

post-transplant infection monitoring and renal function surveillance

Infectious complicationsMultiple cited studies report bloodstream, CMV, and fungal infections during the first year after small bowel transplantation

Renal surveillanceReferences describe renal failure and renal histology outcomes after intestinal transplantation, supporting postoperative renal monitoring

Transplant Center Requirements

Note
Center requirements — no specific accreditation/volume listed
The document does not state specific transplant center accreditation or minimum volume requirements in this section; general OPTN/UNOS program standards and referenced national guidelines inform center-level expectations.
No explicit center accreditation or volume thresholds listed in this portion of the policy.
References to OPTN policies and national guidelines may inform center standards.

Background

Short bowel syndrome and intestinal failure result from loss of absorptive surface of the small intestine such that the patient cannot maintain protein‑energy, fluid, electrolyte, or micronutrient balance. These conditions frequently lead to chronic dependence on total parenteral nutrition (TPN); patients with established long‑term TPN dependence who develop severe TPN‑related complications may be considered candidates for small bowel transplant. Small bowel transplantation requires lifelong immunosuppression and is associated with substantial risks, particularly infection.