CurrentCentenePolicy N/A

Intestinal and Multivisceral Transplant (clinical policy)

Provides reference citations and administrative reminders for an intestinal and multivisceral transplant clinical policy maintained by Centene; affects providers and administrators applying the policy for members/enrollees.

Policy Summary

PayerCentene

PolicyIntestinal and Multivisceral Transplant (clinical policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFollow Health Plan authorization procedures when the clinical policy requires plan-level authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9-21references cited

2018copyright year

Medicare/Medicaidapplicability notes

Coverage Criteria

Coverage determinations under this clinical policy are a guide to medical necessity and do not guarantee payment. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy, contract of insurance) and to applicable state and federal requirements and Health Plan-level administrative policies and procedures. Providers should verify member-specific benefits, limitations, and prior authorization requirements with the member's plan before delivering services.

Provider Actions and Administrative Notices

Prior Authorization

Prior Authorization and Plan-Level Requirements

Authorization governed by Health Plan procedures. Prior authorization and plan-level authorization requirements apply as determined by the member's Health Plan. Providers should follow the Health Plan's established authorization processes before scheduling services.

Prior authorization may be required per Health Plan rules.
Authorization processes and forms vary by plan — verify with the member's Health Plan.

Policy Summary

PayerCentene

PolicyIntestinal and Multivisceral Transplant (clinical policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFollow Health Plan authorization procedures when the clinical policy requires plan-level authorization.

SourceLink

On This Page

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Documentation Required

Provider Responsibility and Administrative Constraints

Important reminder to providers: This clinical policy is a guide to medical necessity and does not replace professional judgment. Coverage determinations remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable Health Plan administrative policies.

Providers retain responsibility for medical advice and treatment decisions.
Coverage is subject to contract language (EOC, certificate, policy).

Note

Effective Date and Change Notice

Policy effective date and change notice: The clinical policy is effective as of the date determined by the Health Plan. The date the policy is posted may differ from its effective date. The Health Plan may change, amend, or withdraw this clinical policy at any time; applicable legal and regulatory requirements take precedence.

Posting date may not equal effective date — confirm effective date with the Health Plan.
Policy may be amended or withdrawn; follow plan notices for changes.

Note

Medicare Cross-Check Required

Medicare coverage cross-check: For Medicare members, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying this clinical policy to ensure consistency with Medicare requirements.

Check relevant NCDs, LCDs, and Medicare Coverage Articles before applying policy criteria.
Medicare requirements supersede when applicable.

Note

Important Reminder

This clinical policy was developed from current standards of medical practice and external sources. The Health Plan makes no representations regarding external content and accepts no liability for its use.

Policy content is property of the Health Plan and protected by copyright.
For Medicaid members, state Medicaid provisions take precedence over this clinical policy when conflicts exist.

Evaluation Requirements

Documentation Required

See full policy for pre-approval evaluation requirements

Refer to the full clinical policy for the required pre-approval workup and evaluation steps for intestinal and multivisceral transplant candidates; this excerpt does not specify the evaluation requirements.

Full evaluation and pre-approval workup details are in the main policy.

Center Requirements

Documentation Required

Refer to main policy for center accreditation and volume requirements

Center accreditation, volume, and credentialing requirements are not specified in this excerpt; providers must follow the main policy and applicable Health Plan center requirements when seeking approval.

Consult the main policy for specific accreditation and volume thresholds.

Background and Rationale

This section provides select literature references and clinical context relevant to intestinal and multivisceral transplantation, including outcomes data and guideline sources used to inform the policy. The clinical policy was developed by experienced, licensed clinicians after review of peer-reviewed literature, evidence-based guidelines, government approvals, and expert clinical opinion; it is intended to guide medical necessity decisions while recognizing that treating clinicians retain clinical judgment.

Definitions

Clinical policy definition

DefinitionClinical policy: a guide to medical necessity used to assist coverage decisions and the administration of benefits; it is not a contract or a guarantee of payment or results.

Source and authorshipDeveloped by experienced, licensed health care professionals based on peer‑reviewed literature, guidelines, agency approvals, and clinician input.

Scope and purposeProvides guidance to determine medical necessity and support coverage decisions; supports but does not replace clinical judgment.

LimitationsDoes not guarantee coverage — decisions remain subject to the member's coverage documents, state and federal requirements, and Health Plan administrative policies.

ApplicabilityApplies to Health Plans that have adopted this clinical policy and are operated or administered by Centene Management Company, LLC or its affiliates.

Post-Transplant References and Coverage Notes

Reference materials

Key literatureVianna RM et al., Ann Surg. 2012;255(6):1144-1150 — Multivisceral transplantation for diffuse portomesenteric thrombosis.

Outcomes and graft selectionHawksworth JS et al., Am J Transplant. 2018;18(6):1312-1320 — Visceral transplantation in patients with intestinal-failure associated liver disease: indications, graft selection, and outcomes.

Guidelines on chronic intestinal failurePironi L et al., Clin Nutr. 2016;35(2):247-307 — ESPEN guidelines on chronic intestinal failure in adults.

Comprehensive reviewsBharadwaj S et al., Gastroenterol Rep (Oxf). 2017;5(1):20-28 — Current status of intestinal and multivisceral transplantation.

Administrative and policy noticesThis clinical policy was developed using peer-reviewed literature and guidance; effective date, change notices, and Medicare cross-checks are governed by Health Plan procedures — review NCDs/LCDs for Medicare members.