CurrentCentenePolicy CP.MP.58

Intestinal and Multivisceral Transplant

Medical necessity criteria and coding guidance for isolated intestinal, combined intestinal-liver, and multivisceral transplantation for pediatric and adult members/enrollees with irreversible intestinal failure.

Policy Summary

PayerCentene

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the member meets one indication (e.g., TPN failure, severe short bowel) and has no listed contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedure types

13contraindications

>=2central vein thromboses

Codes listedcodes provided

Centenepolicy owner

Coverage and Medical Necessity Criteria

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.

Procedure criteria (medical necessity)

Covered when the member/enrollee meets ANY one of the indications in A and has NONE of the contraindications in B

Overall: Member/enrollee must have one indication (A) AND must NOT have any contraindication (B)

From II: A and B must be satisfied

Indications (A)

Failure of total parenteral nutrition (TPN) as indicated by one of the following: (a) impending or overt TPN-related liver failure (elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro‑esophageal varices, coagulopathy, peristomal bleeding, or hepatic fibrosis/cirrhosis); (b) thrombosis of ≥ two central veins (including jugular, subclavian, femoral); (c) two or more episodes per year of systemic sepsis due to line infection OR one episode of septic shock, acute respiratory distress syndrome, and/or line‑related fungemia; (d) frequent episodes of dehydration despite IV fluid supplementation; (e) other complications leading to loss of vascular access.
Other indications: High risk of death without transplant; severe short bowel syndrome (residual small bowel <10 cm in infants and <20 cm in adults); frequent hospitalizations for complications directly related to intestinal failure; significant hepatic cirrhosis associated with diffuse post‑mesenteric thrombosis.

Contraindications (B)

Not covered if ANY of the following contraindications are present

Contraindications list: Malignancy with high risk of recurrence or death related to cancer; other severe uncontrolled medical condition expected to limit survival after transplant; glomerular filtration rate < 40 mL/min/1.73m2 unless being considered for multi‑organ transplant; HIV infection with detectable viral load; presence of other GI diseases; acute liver failure, or cirrhosis with portal hypertension or synthetic dysfunction unless being considered for multi‑organ transplant; septic shock; progressive cognitive impairment; stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within 30 days; chronic infection with highly virulent and/or resistant microbes that are poorly controlled pre‑transplant; inability to adhere to the regimen necessary to preserve the transplant even with caregiver support; absence of an adequate or reliable social support system; active substance use or dependence including current tobacco use, vaping, marijuana use (unless prescribed by a licensed practitioner), or IV drug use without convincing evidence of risk reduction behaviors (exceptions for urgent timelines with commitment to reduce behaviors).

Any one contraindication precludes coverage

Codes listed in this policy are provided for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference current professional coding guidance and the most recent CPT/HCPCS manuals prior to claim submission. The CPT and HCPCS codes shown in this policy (for example, 44135, 44136, 44715, 44720, 44721, 47135, 47143, and HCPCS S2053, S2054, S2055, S2152) describe intestinal, liver, and multivisceral transplant procedures and related graft preparation services but are not a substitute for official coding resources.

Coverage determinations based on this clinical policy are subject to the member's benefit documents. This policy is intended as a guide to medical necessity and does not constitute a contract, guarantee of payment, or substitute for the Health Plan’s benefit, administrative, or contractual requirements. Final coverage decisions and benefit administration remain subject to the terms, conditions, exclusions, and limitations of the member’s coverage documents (for example, evidence of coverage, certificate of coverage, policy, or contract of insurance) and applicable state and federal rules.

Transplant requests will be considered not medically necessary when any one of the listed contraindications is present. Examples of contraindications that preclude coverage include: malignancy with high risk of recurrence or death related to cancer; other severe uncontrolled medical conditions expected to limit post-transplant survival; glomerular filtration rate < 40 mL/min/1.73 m2 unless the member is being considered for a multi-organ transplant; HIV infection with detectable viral load; septic shock; progressive cognitive impairment; recent major cardiovascular or cerebrovascular events within 30 days; chronic uncontrolled infections with highly virulent or resistant organisms; inability to adhere to required post-transplant regimen; inadequate social support; and active substance use or dependence without convincing evidence of risk reduction behaviors.

Coding and Billing Guidance

Covered CPT Codes (presented)CPT

44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; from living donor.
44715	Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein.
44720	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each.
44721	Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each.
47135	Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age.
47143	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; without trisegment or lobe split.

Additional CPT CodesCPT

47144	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with trisegment split of whole liver graft into two partial liver grafts.
47145	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with lobe split of whole liver graft into two partial liver grafts.
47146	Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each.
47147	Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each.

HCPCS CodesHCPCS

S2053	Transplantation of small intestine and liver allografts.
S2054	Transplantation of multivisceral organs.
S2055	Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor.
S2152	Solid organs(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition.

inv-09: Residual small bowel length — <10 cm in infants; <20 cm in adults

Residual small bowel length — infants<10 cm

Residual small bowel length — adults<20 cm

Clinical contextSevere short bowel syndrome defined by residual small bowel thresholds used to indicate transplant candidacy

inv-10: Glomerular filtration rate (GFR) — < 40 mL/min/1.73m2 (contraindication unless multi-organ transplant)

GFR threshold< 40 mL/min/1.73m2

ExceptionNot an absolute contraindication when being considered for multi‑organ transplant

Policy consequenceGFR < 40 without multi‑organ consideration is listed as a contraindication and may lead to denial

Evaluation and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and governed by the member's Health Plan. Providers must obtain approval prior to scheduling transplantation procedures; lack of prior authorization may result in denial of coverage.

Prior authorization governed by Health Plan
Obtain approval before scheduling transplant procedures

Denial Risk

Clinical Indications and Contraindications

Documentation must clearly state clinical indications and any contraindications. Contraindications may lead to denial of the request if not addressed or if present (see policy criteria for specific contraindications).

Clinical indication and contraindication documentation — show how member meets one of the procedure indications and that no exclusionary contraindications apply
Contraindications may cause denial if documentation demonstrates they are present

Documentation Required

Provider Responsibility and Evaluation Requirements

Provider is responsible for submitting complete medical records and supporting documentation demonstrating medical necessity. Evaluation should include TPN failure criteria, vascular access status, history of sepsis, small bowel length, liver disease severity, and any other relevant comorbidities. Incomplete documentation or failure to demonstrate that criteria are met may result in denial.

Provider responsibility and documentation — include TPN failure details, number/type of central vein thromboses, episodes of line-related sepsis, evidence of liver disease (labs, imaging, biopsy), small bowel length/surgical history, vascular access status, and prior treatments
Evaluation requirements — document criteria such as impending/overt TPN-related liver failure, loss of vascular access, frequent dehydration, high risk of death without transplant, and frequent hospitalizations related to intestinal failure

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for intestinal and multivisceral transplants

Requests for intestinal and multivisceral transplantation require prior authorization; the review will assess that one of the procedure indications is met and that no contraindications are present.

Relevant procedure and HCPCS/CPT codes should be included with the authorization request (codes listed in policy).

Note

Prior authorization governed by the Health Plan and benefit documents

This clinical policy is a guide to medical necessity used to assist coverage decisions; applicable prior authorization requirements, benefit determinations, and administrative procedures are governed by the member's Health Plan and benefit documents.

Verify and follow the Health Plan's specific prior authorization processes and any plan-level rules or state/federal requirements.

Documentation Required

PROVIDER ACTION: Include complete clinical documentation with prior authorization

Submit all required clinical documentation with the authorization request, including indication, supporting objective data, and evaluations described in the policy; failure to provide the requested documentation may delay or result in denial of the request.

Include operative reports, imaging, laboratory data, vascular access history, and records of hospitalizations/sepsis episodes as applicable.

Documentation Required

PROVIDER ACTION: Ensure records address indications and contraindications

Provide all requested medical records and evidence demonstrating that the member meets the policy indications and does not have any disqualifying contraindications; the policy lists specific documentation elements reviewers will use.

Ensure records clearly show which indication is met (eg, TPN failure criteria with specific lab/clinical findings) and explicitly address each potential contraindication.

Documentation Required

Provider responsibility: exercise professional judgment and document care

Respond to requests for additional information and exercise clinical judgment when documenting care; the provider remains responsible for medical advice and treatment of the member.

Maintain thorough documentation to support medical necessity and conformity with coverage rules.

Denial Risk

Denial risk if any listed contraindication is present

The presence of any listed contraindications may result in denial of transplant coverage; examples include malignancy with high recurrence risk, GFR <40 mL/min/1.73m2 (unless considered for multi-organ transplant), detectable HIV viral load, septic shock, and active substance use without evidence of risk reduction.

If a contraindication exists, document rationale for consideration of exception (eg, multi-organ transplant) or clearly document mitigation steps and supporting evidence.

Billing Rule

Coverage subject to member's plan terms and limitations

Coverage decisions are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents; failure to meet those plan-level requirements may also trigger denial regardless of meeting clinical criteria.

Confirm member eligibility and benefit coverage in the applicable evidence of coverage or contract before proceeding.

Contraindications (Detailed List)

Contraindications that will preclude coverage are listed comprehensively and include: malignancy with high risk of recurrence or death related to cancer; other severe uncontrolled medical conditions expected to limit survival after transplant; glomerular filtration rate < 40 mL/min/1.73 m2 (unless multi‑organ transplant is planned); HIV infection with detectable viral load; presence of other gastrointestinal diseases that would affect outcomes; acute liver failure or cirrhosis with portal hypertension or synthetic dysfunction (unless considered for multi‑organ transplant); septic shock; progressive cognitive impairment; recent stroke, acute coronary syndrome, or myocardial infarction within 30 days; chronic infection with highly virulent/resistant microbes that are poorly controlled pre‑transplant; inability to adhere to the regimen even with caregiver support; absence of adequate or reliable social support; and active substance use or dependence (including current tobacco, vaping, marijuana use unless prescribed, or IV drug use) without convincing evidence of risk reduction behaviors.

Definitions and Key Terms

inv-20: Short bowel syndrome (SBS) — Condition occurring when approximately <200 cm of small bowel remains

SBS definition — small bowel lengthOccurs when approximately <200 cm of small bowel remains

Clinical consequenceLeads to intestinal failure and dependence on parenteral nutrition

Normal small intestine lengthVaries widely (approximately 3–8 meters), making SBS a relative deficit

inv-21: Failure of total parenteral nutrition (TPN) — TPN-related complications such as impending/overt liver failure, ≥2 central vein thromboses, recurrent line sepsis, frequent dehydration, etc.

TPN failure — liver injuryImpending or overt TPN-related liver failure (elevated bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro-esophageal varices, coagulopathy, peristomal bleeding, or hepatic fibrosis/cirrhosis)

TPN failure — vascular thrombosisThrombosis of ≥ two central veins (jugular, subclavian, femoral)

TPN failure — bloodstream infectionsTwo or more episodes/year of systemic sepsis due to line infection, or one episode of septic shock, ARDS, or line-related fungemia

TPN failure — dehydration and access lossFrequent episodes of dehydration despite IV fluids or other complications leading to loss of vascular access

inv-22: Health Plan — Definition of 'Health Plan' for the policy

Health Plan definitionA health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates

Policy purposeProvides a guide to medical necessity to assist coverage decisions and administering benefits

Not a contractThis clinical policy does not constitute a contract or guarantee regarding payment or results; coverage is subject to terms and conditions of coverage documents

OpenPayer

Intestinal and Multivisceral Transplant

Coverage and Medical Necessity Criteria

Coding and Billing Guidance

Candidate Eligibility by Transplant Type

Evaluation and Documentation Requirements

Provider Actions, Prior Authorization, and Documentation

Center and Specialist Requirements

Post-Transplant Coverage Notes

Contraindications (Detailed List)

Definitions and Key Terms

Clinical Background