Document TPN intolerance / TPN-related complications

Provide documentation demonstrating evidence of intolerance to total parenteral nutrition (TPN) or TPN-related complications when requesting evaluation or authorization for intestinal transplant. Examples cited in the policy include multiple or prolonged hospitalizations for TPN complications, catheter-related sepsis, progressive liver disease, and loss of venous access.

• Multiple and prolonged hospitalizations to treat TPN-related complications
• Catheter-related sepsis or recurrent catheter-related infections
• Progressive liver disease attributable to TPN (e.g., elevated bilirubin)
• Inability to maintain venous access for long-term TPN

Provide specific event-level evidence of TPN intolerance

When documenting TPN intolerance for transplant evaluation, include specific examples and objective events that meet the policy’s definition of TPN-related complications (hospitalizations, catheter-related sepsis, progressive liver failure, or loss of venous access) to support medical necessity.

• Cite hospital admissions and reason(s) for admission related to TPN complications
• Provide microbiology and treatment details for catheter-related sepsis episodes
• Document liver dysfunction attributed to TPN (see bilirubin threshold referenced elsewhere)
• Describe attempts and failures to maintain venous access

Cite referenced clinical guidelines and position statements

Reference guideline and position statements used in the policy when planning evaluation and management; the policy cites AGA clinical updates, AST/ASG pediatric position papers, British Transplantation Society guidance, OPTN policies, and the CMS NCD as supporting clinical resources.

• American Gastroenterological Association position statements and clinical updates (AGA)
• American Society of Transplantation pediatric position paper
• British Transplantation Society guidelines
• Organ Procurement and Transplantation Network (OPTN) policies and CMS National Coverage Determination

Avoid candidates with listed contraindications

Do not submit transplant requests for individuals with conditions listed as potential contraindications; the policy identifies current malignancy, recent malignancy with high recurrence risk, untreated systemic infection, other irreversible end-stage disease, systemic disease worsened by immunosuppression, and psychosocial or chemical dependency issues.

• Known current malignancy, including metastatic cancer
• Recent malignancy with high risk of recurrence or history of cancer with moderate risk of recurrence
• Untreated systemic infection or chronic infection making immunosuppression unsafe
• Other irreversible end-stage disease not attributed to intestinal failure
• Systemic disease that could be exacerbated by immunosuppression
• Psychosocial conditions or chemical dependency affecting adherence

Futility or inability to manage post-transplant care may trigger denial

Be aware that transplantation will be denied when the procedure is expected to be futile due to comorbid disease or when post-transplant care is expected to significantly worsen comorbid conditions; document assessments that show the patient is not in such a futility category.

• Demonstrate that comorbid conditions do not render transplantation futile
• Show that post-transplant management is not expected to significantly worsen existing comorbidities

Administrative note — policy statements unchanged

Administrative reviews have not changed core policy statements; the policy history documents editorial updates only and does not list additional documentation-related denial risks in these sections.

• Policy history notes multiple consensus reviews with no change to policy intent
• Documentation-related denial risks are not specified in the administrative history

Prior authorization required to establish medical necessity

Obtain prior authorization to establish medical necessity for isolated small bowel transplant, small bowel/liver transplant, multivisceral transplant, and applicable retransplantation; authorization must document intestinal failure with long-term TPN dependence and TPN-related complications or progressive liver failure as applicable.

• Prior authorization required for isolated small bowel, small bowel/liver, multivisceral transplant, and retransplantation
• Must document intestinal failure with long-term TPN dependence and relevant TPN-related complications or progressive liver failure

Prior authorization required for listed procedure codes

Submit prior authorization requests for the specific procedure codes listed in the coding section; coverage determination remains subject to member benefit terms and the prior authorization process.

• Transplant procedure codes listed in the coding section must be used on requests
• Coverage is determined by medical necessity and member benefit provisions

Coding update: CPT 44799 noted (PA details not specified)

Note that the policy’s coding table was updated to include CPT 44799; prior authorization processes reference the coding table but specific PA workflows are not detailed in these chunks.

• Coding table includes CPT 44799 (unlisted intestine procedure)
• Prior authorization requirements are not specifically outlined in the cited coding/authorization notes

Document prior conservative and medical therapies

Document efforts at conservative and medical therapies prior to transplant evaluation; the policy notes nutritional optimization, attempts at enteral feeding, pharmacologic measures, and surgical bowel-preserving procedures as prior treatment considerations.

• Nutritional optimization and attempts at enteral feeding
• Pharmacologic agents to enhance absorption or slow transit
• Surgical bowel-preserving techniques

Submit cardiopulmonary status, compliance, and TPN-intolerance evidence

Include documentation demonstrating adequate cardiopulmonary status and patient compliance with medical management when requesting authorization; also provide objective evidence of intolerance to alternatives such as TPN complications, prolonged hospitalizations, catheter-related sepsis, progressive liver disease, or loss of venous access.

• Evidence of adequate cardiopulmonary evaluation
• Documentation of patient compliance with medical therapy
• Clinical records supporting TPN intolerance (hospitalizations, infections, liver dysfunction, venous access issues)

Submit procedure/diagnosis codes and supporting medical necessity documentation

When submitting for authorization, include the applicable procedure and diagnosis codes from the policy’s coding section and supporting clinical documentation to demonstrate medical necessity; presence of a code in the list does not guarantee coverage.

• Use codes listed in the policy (see coding table) for procedures and diagnoses
• Attach documentation supporting medical necessity per member benefit rules
• Code listing does not by itself denote coverage

Policy history: coding table updated (added CPT 44799)

The coding table was updated in the policy history; CPT 44799 (unlisted intestine procedure) was added per the policy history and coding sections.

• CPT 44799 added to the coding table per policy history
• Refer to the coding section for current code listings

Do not authorize transplants for listed contraindications

Do not proceed with transplant authorization for patients with current malignancy, recent malignancy with high recurrence risk, untreated systemic infection, or other irreversible end-stage disease not due to intestinal failure; these are listed as contraindications that may preclude coverage.

• Known current malignancy, including metastatic disease
• Recent malignancy with high risk of recurrence
• Untreated systemic or chronic infection
• Other irreversible end-stage disease not attributed to intestinal failure

Futility and post-transplant management concerns may trigger denial

Be aware that transplantation requests may be denied if judged futile due to comorbid disease or if post-transplant care is expected to significantly worsen comorbid conditions; include assessments showing these risks are not present.

• Document evaluations demonstrating transplant is not expected to be futile
• Address how post-transplant care will not significantly worsen comorbidities

Administrative note — no change to policy statements across reviews

Administrative policy reviews have not altered policy statements; the history records editorial and coding updates only and does not list additional documentation-based denial risks in these administrative notes.

• Multiple consensus reviews with no change to policy statements
• Administrative edits and coding reviews noted in policy history

Transplant center assessment required for candidate selection

Transplant center judgment applies for contraindications and candidate selection; the policy explicitly states transplant center assessment is required when applying general criteria and candidate requirements.

• Transplant center assesses and judges contraindications
• Center documents candidate fitness and eligibility

Center judgment applies to contraindications and candidate fitness

Transplant centers must apply their clinical judgment when evaluating candidates, including assessment of cardiopulmonary status, compliance, and whether contraindications exist; the policy defers these determinations to the center.

• Center documents adequate cardiopulmonary status and compliance
• Center determines presence or absence of listed contraindications

Document center-level evaluation and multidisciplinary assessment

Transplant centers should follow standard transplant evaluation and workup processes and document center-level assessments; the policy references candidate criteria and defers specific center requirements to the transplant program judgment.

• Document center-specific evaluation and multidisciplinary assessments
• Provide center rationale when exceptions or complex comorbidities exist

Adhere to OPTN and CMS program requirements and referenced resources

Centers should adhere to national program requirements and referenced resources; the policy cites OPTN policies and the CMS National Coverage Determination as relevant program-level guidance.

• Follow OPTN policies and CMS NCD for intestinal and multivisceral transplantation
• Use referenced national guidelines to inform center practices