Small Bowel Transplant
Customize your policy alerts
Sign up for blue cross blue shield - south dakota Policy 07.03.04 alerts
Get alerted when Policy 07.03.04 changes without checking for updates manually.
Monitor payer policy activity
Criteria, coverage stance, and evidence summary for isolated small bowel transplantation and retransplantation for adults and pediatric patients with intestinal failure, including prior authorization requirements and investigational exclusions.
No material clinical or coverage changes in this revision.
Coverage Criteria for Small Bowel Transplantation
Initial Cadaveric Small Bowel Transplant
Covered when ALL of the following are met:
See Policy Guidelines for definition of severe complications (progressive TPN-induced liver failure, frequent dehydration despite TPN, thrombosis of two or more major central venous channels, or frequent central line–related sepsis).
Initial Living Donor Small Bowel Transplant
Living donor option contingent on unavailability of cadaveric organ and meeting cadaveric criteria.
Retransplant
Covered when ALL of the following are met:
Retransplant may be cadaveric or living donor if criteria met; documentation of prior transplant failure and indication required.
Investigational
Not covered / investigational for the following:
Insufficient evidence that transplantation improves net health outcomes in these situations.
General medical necessity considerations
Coverage considerations are informed by randomized and observational evidence; patient selection should reflect intestinal failure and prior management with TPN.
Evidence base is mainly case series; timing and earlier transplantation remain areas of uncertainty.
Evidence summary
Outcomes and risk profile based on case series evidence:
See case series summaries and systematic review references for detailed survival and off-TPN rates.
Complications and adverse events
Adverse events and complications that affect coverage decisions:
These risks require documented discussion and management plans as part of the transplant evaluation and post-transplant care.
Small bowel retransplantation — coverage criteria
Covered when ALL of the following are met:
Available data are limited to small case series and registry analyses; selection should be restricted to patients likely to benefit.
HIV-positive transplant recipient criteria
Covered when ALL of the following are met for HIV-positive recipients:
Reflects OPTN/UNOS permissive policy and British HIV Association/British Transplantation Society guidance extrapolated to intestinal transplantation.
Small bowel transplantation is considered investigational for individuals who are able to tolerate total parenteral nutrition (TPN) and in any other situation where the specified coverage criteria are not met. (See investigational exclusions.)
There is insufficient evidence to support routine earlier transplantation for patients who do not have severe complications from TPN; randomized trials comparing intestinal transplantation with long‑term TPN are lacking and optimal timing for earlier transplant has not been established.
Contraindications to intestinal transplantation include conditions similar to other solid‑organ transplants, such as profound neurologic disability, life‑threatening comorbidities, severe immunologic deficiencies, and nonresectable malignancy. Transplant centers should assess and document these and other exclusionary conditions when evaluating candidates.
The document extract lists the relevant procedure and place‑of‑service coding (eg, CPT 44135 and 44136) and notes the service type as inpatient surgery; however, this portion of the extract does not include explicit clinical coverage criteria or additional medical‑necessity rules beyond those provided elsewhere in the policy.
Small bowel transplant is not routinely performed for all patients with intestinal failure; it is reserved for individuals who develop severe TPN‑related complications or experience high morbidity despite TPN, where transplantation may address life‑threatening or functionally limiting sequelae of long‑term parenteral nutrition.
Candidate Selection and Indications
Candidate criteria
See Policy Guidelines for specific severe complications definitions and transplant contraindications.
Transplant candidate selection
Candidate selection should focus on patients with intestinal failure who have failed or have life-threatening complications from TPN.
Evidence does not define optimal timing for transplant; earlier transplantation remains investigational except in listed indications.
Indications and referral
General candidate considerations and referral triggers:
These indications align with CMS and specialty society recommendations; transplant center judgment required for individual decisions.
Contraindications to Small Bowel Transplant
Known current malignancy, including metastatic cancer, is a contraindication to transplantation. Recent malignancy with a high risk of recurrence and histories of cancer with moderates risk of recurrence also typically preclude listing until risk is acceptably low and documented per center policy and oncology input.
Untreated systemic infection or other irreversible end‑stage disease not attributable to intestinal failure are contraindications because required immunosuppression would pose unacceptable risk. Similarly, systemic diseases that are likely to be worsened by immunosuppression should be considered exclusionary.
Psychosocial conditions or active chemical dependency that impair the candidate's ability to adhere to lifelong post‑transplant care and immunosuppression are contraindications to listing for intestinal transplantation and must be assessed and documented by the transplant center.
Insufficient vascular patency (for example, loss of central venous access or thrombosis of major central venous channels) that would preclude safe vascular anastomosis or postoperative care is a potential contraindication and should be evaluated during candidate workup.
Guidance from specialty societies (eg, AGA) aligns contraindications with CMS‑approved indications, emphasizing that candidates with ongoing malignancy, uncontrolled systemic illness, or other conditions that substantially increase perioperative or long‑term risk are not appropriate transplant candidates.
In pediatric populations, contraindications mirror adult solid‑organ transplant exclusions and include autoimmune diseases or anatomical issues (such as insufficient vascular patency) that would prevent successful grafting or post‑transplant care.
Transplant centers must document absence of active opportunistic infections and ensure that other infection risks are controlled prior to proceeding with transplantation; uncontrolled infection is a contraindication to effective immunosuppression and graft survival.
HIV infection is not an absolute contraindication to intestinal transplantation. HIV‑positive candidates may be considered if they meet specific criteria (eg, adherence to antiretroviral therapy, sustained CD4 count >100 cells/mL—ideally >200—and durable viral suppression) consistent with OPTN/UNOS policy and extrapolated guidance from kidney/pancreas HIV recommendations.
A history of recent malignancy with a high risk of recurrence, nonresectable malignancy, or prior cancers with unresolved recurrence risk should generally exclude candidates until cancer‑specific disease‑free intervals and oncologic clearance are documented per center and national guidance.
Provider Actions, Prior Authorization, and Documentation
Prior approval required
Prior approval is required for small bowel transplantation; initial cadaveric small bowel transplant is considered medically necessary only when the individual has intestinal failure, established long‑term dependency on total parenteral nutrition (TPN), and is developing or has developed severe complications from TPN.
- Prior approval required for inpatient surgical transplant services.
Confirm indication and alternatives during prior auth
When requesting prior authorization, confirm the patient has intestinal failure and that small bowel transplantation (the requested intervention) is being sought as an alternative to medical management/TPN; the request should document consideration of reasonable alternatives such as continued medical management and parenteral nutrition.
- Confirm population: intestinal failure (unable to maintain nutrition/ hydration enterally)
- Document that small bowel transplant is the requested intervention and alternatives (medical management/TPN) were considered
Prior auth for retransplant — document prior graft failure and candidacy
For requests for small bowel retransplantation, document that the prior primary small bowel graft failed for an indicated reason (eg, acute rejection requiring enterectomy, chronic rejection, non‑function, or return of disease) and that the candidate continues to meet standard transplant eligibility criteria before prior authorization is approved.
- State reason for prior graft failure and supporting registry or center data (UNOS/center records)
- Confirm patient still meets initial transplantation candidacy requirements
Obtain prior authorization and use correct CPT codes
Obtain prior authorization for intestinal allotransplantation procedures and report the appropriate CPT codes with the authorization request; CPT 44135 describes intestinal allotransplantation from a cadaver donor and CPT 44136 describes intestinal allotransplantation from a living donor.
Living donor allowed only if cadaveric intestine unavailable
Document donor availability when proposing a living‑donor small bowel transplant: living‑donor transplantation may be considered medically necessary only when a cadaveric intestine is not available and the candidate meets criteria for cadaveric transplant.
- State why a cadaveric intestine was not available
- Confirm the candidate meets all criteria for cadaveric small bowel transplant
Document failed or complicated TPN prior to transplant
Prior authorization requests must document failure of, or life‑threatening complications from, TPN when applicable; the policy requires demonstration that continued medical management/TPN is insufficient or complicated (eg progressive TPN‑induced liver failure, recurrent central line–related sepsis, loss of venous access, or frequent severe dehydration).
- Describe duration of TPN dependence and specific TPN‑related complications (see severe complications definition)
- Explain why continued TPN/medical management is not a viable option
Document conservative therapy and PPN attempts
Document attempts at conservative therapy and parenteral nutrition management before transplantation is approved; conservative management (medical management and parenteral nutrition) is the comparator and should be recorded as attempted or considered.
- Describe medical management strategies attempted
- Record duration and outcomes of parenteral nutrition/PPN trials and rationale for moving to transplant
Submission checklist (brief actionable summary)
Provide a concise actionable note summarizing the submission: include indication, TPN history/complications, donor type requested, prior transplant history (if any), and relevant codes to expedite review.
Document absence of contraindications and ability to adhere
Transplant centers must assess and document absence of contraindications and the candidate’s ability to adhere to post‑transplant care and lifelong immunosuppression; potential contraindications include active malignancy, untreated systemic infection, other irreversible end‑stage disease, or psychosocial/chemical dependency limiting adherence.
- Document assessment that no listed contraindications are present
- Describe plan to ensure adherence to post‑transplant care and immunosuppression
Required clinical documentation for prior auth
Include required clinical documentation with the prior authorization: indication of intestinal failure, prior management including duration and complications of TPN, the specific transplant type requested (isolated intestinal, combined liver‑intestine, or multivisceral), and expected outcomes including likelihood of weaning from TPN.
- Indication and detailed TPN history (duration, complications)
- Requested transplant type and anticipated benefits (eg potential to wean from TPN)
Document prior transplant history and registry/outcome data
For retransplantation requests, submit prior transplant history, the reason for retransplant, and available registry or center outcome data (eg UNOS/center registry reports) to support the need for repeat transplantation.
- Prior graft details and reason for failure
- UNOS or center registry outcome data, if available
Policy contact for submissions
Send medical policy questions or new relevant information to the Wellmark Blue Cross and Blue Shield Medical Policy Analyst at the address provided for policy submissions.
- Wellmark Blue Cross and Blue Shield Medical Policy Analyst, PO Box 9232, Des Moines, IA 50306-9232
Prior authorization requirement and investigational exclusions may cause denial
Prior approval is required and procedures that do not meet the stated medical necessity criteria — or that fall into investigational exclusions (for example, patients able to tolerate TPN or when criteria are not met) — may be denied.
- Claims for situations not meeting criteria or listed as investigational are subject to denial
Evidence limitations may influence approval decisions
Be aware that evidence limitations (no randomized trials comparing transplantation vs long‑term TPN) create uncertainty in timing/indication decisions; earlier transplantation without meeting criteria may be challenged in review.
- Lack of randomized comparative trials may affect approval of earlier transplant requests
HIV donor‑recipient restrictions and recipient HIV criteria
Follow OPTN/UNOS restrictions for HIV donor‑recipient matching: organs from HIV‑positive donors are to be used only for HIV‑positive recipients; ensure the recipient meets HIV‑specific criteria (ART adherence, CD4 >100 cells/mL ideally >200, undetectable viremia) before proceeding.
- Confirm donor‑recipient HIV status alignment with OPTN/UNOS policy
- Document recipient HIV criteria (ART adherence, CD4 and viral load thresholds)
Coding and Billing
Pre-transplant Evaluation and Center Requirements
Center assessment: contraindications and adherence
The transplant center must assess and document the patient's contraindications and demonstrate the patient's ability to adhere to post‑transplant care and lifelong immunosuppression as part of the evaluation.
Evaluate infection risk, donor matching, renal and immunologic factors
Pre‑transplant evaluation should include assessment of infection risk, donor matching considerations (living vs cadaveric donors), renal function, and risk factors for antibody‑mediated rejection.
Comprehensive pre‑transplant workup and documentation
Complete a comprehensive workup documenting prior transplant failure (if applicable), assessment for TPN‑related complications, infection history, and immunologic status (including HIV viral load and CD4 when relevant).
Reference guidelines and CMS NCD documents in evaluation
Evaluation and indications are informed by referenced guidelines and CMS National Coverage Determination documents; include citation of guideline or NCD evidence when relevant to the request.
Perform transplants at experienced, standards‑compliant centers
Transplantation should be performed at experienced centers; although specific center requirements are not listed in this excerpt, program adherence to OPTN/UNOS and specialty society standards is implied.
Follow OPTN/UNOS and specialty society standards
Centers should follow OPTN/UNOS policies and specialty society guidance when conducting intestinal transplantation, consistent with implied center standards in the evidence base.
Document program capabilities for complex transplant care
Ensure program-level capabilities for complex transplant management (implied by case series and registry data) when seeking authorization.
Include institutional experience and multidisciplinary support
Provide evidence of institutional experience and multidisciplinary support when applicable, as the literature and policy imply preference for experienced centers.
Include OPTN/UNOS and guideline references
Cite OPTN/UNOS policies and relevant specialty guidelines in submissions to demonstrate alignment with accepted transplant standards.
Post-Transplant Surveillance and Ongoing Coverage
Background and Scope
Background: Small bowel transplantation (isolated intestine, combined liver‑intestine, or multivisceral graft) is a treatment option for patients with intestinal failure—commonly due to short bowel syndrome, congenital defects, or severe motility/absorptive disorders—when the patient cannot maintain adequate nutrition or hydration enterally. It is infrequently performed, carries substantial post‑transplant infection and immunologic risk, and is typically considered when long‑term TPN leads to life‑threatening or functionally limiting complications.
Definitions and Key Terms
Revision History
Policy renewed following annual review.
Annual review performed with policy action recorded.
Policy effective date recorded.
Most recent policy action listed as 'Policy Renewed' in policy history.
Policy history records an annual review and associated action in October 2024.
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.