Isolated Small Bowel Transplant and Small Bowel–Liver and Multivisceral Transplant
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Defines medical necessity, investigational indications, and candidate/contraindication considerations for isolated small bowel transplant and combined small bowel–liver or multivisceral transplant for adults and pediatrics dependent on long-term total parenteral nutrition (TPN). Affects Capital BlueCross members and provider prior authorization/coverage decisions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Isolated small bowel transplant — medically necessary
Covered when ALL of the following are met:
Living-donor small bowel transplant may be considered only when cadaveric intestine is not available.
Small bowel–liver or multivisceral transplant — medically necessary
Covered when ALL of the following are met:
Multivisceral transplant is indicated when anatomic or other medical problems preclude small bowel–liver transplant.
Retransplantation
Covered when ALL of the following are met:
Available evidence from case series indicates retransplantation can improve net health outcome in selected patients; retransplantation contraindicated when futile due to comorbid disease or if post-transplant care would significantly worsen comorbid conditions.
Investigational / Not medically necessary indications
Not covered in the following situations:
Insufficient evidence to support benefit in these situations.
Isolated Small Bowel Transplant
Covered when criteria met based on evidence and selection:
HIV infection is no longer an absolute contraindication per current guidelines and U.S. policy.
Small Bowel–Liver and Multivisceral Transplant
Covered when criteria met based on evidence and selection:
Retransplantation of these combinations may be considered in selected patients with supportive case series data.
Retransplantation
Covered when criteria met for retransplantation:
Retransplantation contraindicated when futile due to comorbid disease or if post-transplant care would significantly worsen comorbid conditions.
A small bowel transplant using a living donor is not medically necessary except when a suitable cadaveric intestine is unavailable. When cadaveric intestine is not available, living-donor small bowel transplant may be considered medically necessary only if the individual otherwise meets the policy criteria for a cadaveric intestinal transplant (documented intestinal failure with long-term TPN dependence and severe TPN-related complications).
The existence of this medical policy does not guarantee that a given service is a covered benefit under a member's health benefit plan. Coverage, exclusions, benefit limits, and preauthorization requirements are determined by the member's specific plan language. Providers and members should consult the member's health benefit plan or contact Capital Blue Cross for benefit and preauthorization information.
Small bowel transplant, small bowel–liver transplant, and multivisceral transplant are considered investigational / not medically necessary in situations where the individual with intestinal failure is able to tolerate total parenteral nutrition (TPN). More broadly, these procedures are investigational in all situations that do not meet the specific medical necessity criteria described in this policy because there is insufficient evidence to conclude a net health benefit in those settings.
Candidate Criteria
Candidate criteria for transplant
Candidate requirements referenced in policy:
Candidate criteria — general considerations
General candidate considerations noted in the policy:
Evidence base is primarily case series; specialized center assessment recommended.
Contraindications
Contraindications to transplantation include: known current malignancy (including metastatic cancer), untreated systemic infection (including chronic infections that would make immunosuppression unsafe), and recent malignancy with a high risk of recurrence. Other listed contraindications include irreversible end-stage disease not attributable to intestinal failure, systemic disease likely to be worsened by immunosuppression, history of cancer with moderate recurrence risk, and psychosocial or chemical dependency issues that would impair adherence to therapy.
Transplantation is also contraindicated when the procedure is expected to be futile due to comorbid disease or when required post-transplant care is expected to significantly worsen existing comorbid conditions. These determinations are subject to transplant center judgment and should be made in the context of the individual patient's overall clinical status.
A related contraindication statement reiterates that transplant should not be performed when it would be futile because of comorbid disease or when post-transplant management would materially worsen coexisting conditions. Centers should evaluate whether anticipated post-transplant immunosuppression and care needs will be detrimental to the patient's other medical conditions before approving transplantation.
Pre-Approval Evaluation Requirements
Document compliance, cardiopulmonary status, and TPN intolerance
Pre-approval evaluation must document the patient’s compliance with medical management, adequate cardiopulmonary status, and evidence of intolerance to TPN (for example, multiple/prolonged hospitalizations for TPN complications, repeated catheter-related sepsis, progressive liver failure, or inability to maintain venous access).
- Document patient compliance with medical management.
- Document adequate cardiopulmonary status.
- Provide specific evidence of TPN intolerance (e.g., repeated catheter-related sepsis, progressive liver failure, inability to maintain venous access).
Standard transplant evaluations (center-performed)
Standard transplant evaluations are assumed to be performed by the transplant center; this policy does not enumerate each routine pre-transplant evaluation step.
- Transplant center should perform its usual candidate workup and assessments.
Pre-transplant workup details not specified here
The policy references standard pre-transplant workup implicitly but does not provide detailed step-by-step evaluation protocols in this document.
- Consult center guidelines and cited OPTN/society references for detailed pre-transplant evaluation procedures.
Provider Actions and Requirements
Prior authorization required when medically necessary
Prior authorization is required for isolated small bowel transplant, small bowel–liver transplant, and multivisceral transplant when the medical necessity criteria in this policy are met.
- Obtain prior authorization when requesting coverage for these transplants if criteria are met.
Verify preauthorization per member's benefit plan
Benefit determinations and any preauthorization requirements are governed by the member’s health benefit plan; providers should consult the member’s plan or contact Capital Blue Cross for benefit and preauthorization information.
- Verify member coverage and preauthorization requirements with the applicable benefit plan before scheduling/transplant authorization.
Reference policy MP 9.013 for prior authorization
Consult policy MP 9.013 for coverage determinations when obtaining prior authorization for isolated small bowel and multivisceral transplants.
- Reference MP 9.013 in prior authorization submissions and discussions with the plan.
Use cadaveric intestine first; living-donor only if unavailable
Document consideration of cadaveric intestine as the first option; living-donor small bowel transplant should be considered only when cadaveric intestine is not available and the patient meets the policy criteria for transplant.
- Record that cadaveric organ availability was assessed and documented before pursuing living-donor transplant.
No step therapy specified
The policy does not define any step-therapy sequence for intestinal or multivisceral transplant; no step therapy is specified in this document.
- Do not assume an internal step-therapy ladder is required based on this policy excerpt.
Document intestinal failure etiology, TPN dependence, and compliance
Include documentation of the intestinal failure etiology and the patient’s inability to maintain nutrition without TPN, and evidence of compliance with medical management as part of the authorization record.
- Document cause of intestinal failure (e.g., short bowel syndrome, congenital defect).
- Document long-term dependence on TPN and specific TPN-related complications.
- Document adherence to medical management.
Include coding and consult benefit plan
Provide appropriate procedure and diagnosis codes with authorization requests and consult the member’s benefit plan for coverage determinations; coding lists are included in the policy but coverage is determined by benefit language.
- Include relevant CPT/HCPCS and ICD-10 codes from the policy coding section with submissions.
- Confirm coverage and reimbursement details with the member's plan.
Include referenced OPTN/clinical literature in documentation
Cite the policy references and clinical literature (OPTN, association position statements, and specialty society guidance) in clinical documentation to support transplant coverage requests.
- Attach relevant literature or guideline excerpts referenced in the policy to the authorization request when applicable.
Absolute contraindications that may trigger denial
Known current malignancy, untreated systemic infection, recent malignancy with high risk of recurrence, psychosocial conditions or chemical dependency affecting adherence, and other specified irreversible end-stage diseases are listed potential contraindications that may lead to denial of transplant coverage.
- Known current malignancy (including metastatic cancer).
- Untreated systemic infection (including chronic infection).
- Recent malignancy with high risk of recurrence.
- Other irreversible end-stage disease not attributed to intestinal failure.
- Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.
Contraindications based on futility or worsened comorbidity
Transplantation is contraindicated and may be denied when the procedure is expected to be futile because of comorbid disease or when post-transplant care is expected to significantly worsen the patient’s comorbid conditions.
- Assess and document whether comorbid conditions make the procedure futile or post-transplant care unsafe.
Administrative/coding review risk — verify codes
Policy history notes that coding was reviewed with no coding changes; absence of explicit coding changes in recent reviews may lead to administrative denials if providers use codes not referenced in the policy—verify codes against the policy coding section.
- Confirm codes used for billing are those referenced in the policy and current payer code lists.
- Be aware administrative history indicates coding was reviewed but not changed.
Coding Information
| No codes listed |
| 47135 | Procedure code listed in policy (exact mapping in document) |
| 44133 | Procedure code listed in policy (exact mapping in document) |
| 44135 | Procedure code listed in policy (exact mapping in document) |
| 44136 | Procedure code listed in policy (exact mapping in document) |
| 44137 | Procedure code listed in policy (exact mapping in document) |
| 44715 | Procedure code listed in policy (exact mapping in document) |
| 44720 | Procedure code listed in policy (exact mapping in document) |
| 44721 | Procedure code listed in policy (exact mapping in document) |
| 47133 | Procedure code listed in policy (exact mapping in document) |
| 47399 | Unlisted procedure code referenced in policy |
| K72.00 | Acute and subacute hepatic failure without coma |
| K72.01 | Acute and subacute hepatic failure with coma |
| K72.10 | Chronic hepatic failure without coma |
| K72.11 | Chronic hepatic failure with coma |
| K90.49 | Malabsorption due to intolerance, not elsewhere classified |
| K90.89 | Other intestinal malabsorption |
| K90.9 | Intestinal malabsorption, unspecified |
| K91.2 | Postsurgical malabsorption, not elsewhere classified |
| T86.851 | Intestine transplant failure |
Post-Transplant Coverage and Monitoring
Background
Intestinal failure arises from loss of absorptive capacity of the small intestine due to surgical resection, congenital defects, or disease-associated injury. A common manifestation is short bowel syndrome, in which the remaining intestinal surface is insufficient to absorb macronutrients, fluids, electrolytes, or micronutrients, often leading to chronic dependence on total parenteral nutrition (TPN).
Chronic TPN dependence can result in serious complications that may prompt consideration of transplantation, including repeated or prolonged hospitalizations for TPN-related issues, catheter-related bloodstream infections, progressive TPN-associated liver disease (often associated with total bilirubin levels > 3 mg/dL), and loss of adequate venous access. Small bowel, small bowel–liver, or multivisceral transplant may be appropriate for select patients with these TPN-related complications or with impending end-stage liver disease related to TPN.
Definitions
Center Requirements and Program Access
Center judgment governs candidacy and contraindications
Transplant candidacy determinations and assessment of contraindications are made by the transplant center; outcomes and candidate selection rely on specialized center expertise.
- Centers retain clinical judgment for candidate selection and contraindication evaluation.
Blue Distinction Centers for Transplant (BDCT) referenced
The policy references Blue Distinction Centers for Transplant (BDCT) as a program to provide access to leading transplant centers.
- Consider BDCT designation when selecting a transplant center for referral.
BDCT program referenced (duplicate)
Policy reiterates the BDCT program as a resource for access to leading transplant centers (duplicate reference).
- BDCT is a cooperative program of Blue Cross and Blue Shield Plans to identify leading transplant centers.
Revision History
References updated through 2024 as part of recent policy maintenance and literature review.
Consensus review conducted (policy statements unchanged); administrative updates including coding review noted.
Consensus review completed with no clinical policy statement changes; policy reformatted and HIV guidelines and references updated; coding reviewed.
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