ModifiedCignaPolicy 0288

Intestinal and Multivisceral Transplantation

Defines medical necessity, contraindications, coding, and background for primary and repeat deceased-donor intestinal and multivisceral transplantation and specifies that living-donor intestinal transplantation is not covered. Applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyIntestinal and Multivisceral Transplantation

Policy CodePolicy 0288

Change TypeMaterial modifications (malignancy guidanceliving-donor non-coverage)

Effective DateMar 15, 2026

Next Review DateDec 15, 2026

Key ActionObtain program-level transplant evaluation and oncology clearance and document required wait times for candidates with prior malignancy.

SourceLink

POLICY UPDATE CHANGES

Added policy statements if individual has a history of malignancy

Added policy statement for non-coverage of living-donor intestinal transplantation

Annual review with no policy statement changes recorded for 12/15/2024 and 12/15/2023

70.2% / 53.9% / 49.8%1-/3-/5-yr repeat transplant survival

85% / 61% / 42% / 35%1-/3-/5-/10-yr patient survival (single-center)

10%Retransplantation rate

2-5 years

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.

Common wait times (skin/melanoma)

Not eligibleStatus for distant metastasis

2026-03-15Most recent substantive review

Coverage Criteria for Intestinal and Multivisceral Transplantation

Initial and Repeat Transplant Indications

Covered when ANY of the following indications are present in an individual with total irreversible intestinal failure

Indications list: Failure, contraindication, or intolerance to parenteral nutrition with any of: impending or overt liver failure; impending loss of central vein access (e.g., thrombosis); recurrent, life‑threatening sepsis; frequent episodes of dehydration; high risk of death; severe short bowel syndrome; frequent hospitalizations for complications directly related to intestinal failure; pseudo‑obstruction

Primary and repeat deceased‑donor intestinal and multivisceral transplantation considered medically necessary when any one indication is present

Oncology Clearance Requirement

Covered when BOTH of the following are met

Oncology clearance and criteria: Meets the standard transplant indications above AND has oncology clearance in accordance with published guidelines and does not have a listed contraindication to transplantation

See Appendix for oncologic clearance guidance and documentation requirements

Retransplantation (repeat intestine/multivisceral transplant)

Covered when ALL of the following are met

Retransplantation candidate criteria: Candidate meets all eligibility criteria for primary intestinal/multivisceral transplantation and has no absolute contraindications to transplantation

Individuals undergoing repeat intestinal or multivisceral transplantation must meet primary transplant eligibility and lack absolute contraindications

Skin cancer pretransplant criteria

Covered when meeting recommended treatment and wait-time milestones per cancer type and stage

Cutaneous squamous cell carcinoma (cSCC): Appropriate pretransplant treatment: surgical excision with clear margins or Mohs micrographic surgery for low‑risk lesions. No delay for low‑risk disease. High‑risk cSCC (excluding perineural invasion): surgical excision or Mohs; wait time = 2 years. High‑risk cSCC with perineural invasion or ≥2 risk factors: surgical excision plus adjuvant radiation therapy (ART); wait time = 2–3 years. Local nodal metastatic disease: surgical excision with appropriate lymph node dissection plus ART; wait time = 5 years. Distant metastasis: refer to oncology; not eligible for transplantation.

Follow ITSCC guidance; distant metastasis is an absolute exclusion

Merkel cell carcinoma (MCC): Local disease with negative sentinel lymph node biopsy: wide local excision plus ART; wait time = 2 years. Local disease with nodal metastasis: wide local excision, lymph node dissection, and ART; wait time = 3–5 years. Distant metastasis: refer to oncology; not eligible for transplantation.

Melanoma: In situ melanoma: wide local excision; no wait required and follow‑up at 3 months posttransplant. Stage Ia: wide local excision; wait time = 2 years. Stage Ib/IIIa: wide local excision plus sentinel lymph node biopsy; wait time = 2–5 years. Stage IIb/IIc: wide local excision plus sentinel lymph node biopsy; wait time = 5 years. Any stage III or IV melanoma: refer for oncology; not eligible for transplantation.

Hematologic malignancy pretransplant criteria

Covered when disease-specific survival/relapse milestones and time intervals are met

Diffuse large B cell lymphoma (DLBCL): Event‑free/progression‑free survival milestone achieved (EFS24/PFS24); time interval to transplant = 2 yearsEFS24/PFS24

Survival after EFS24 approximates the age‑ and sex‑matched general population

Follicular lymphoma: EFS24 achieved; time interval to transplant = 2 yearsEFS24

No added mortality after EFS24 compared with general population

Peripheral T‑cell lymphoma, NOS: EFS24 achieved; time interval to transplant = 2 years; note approximately 23% relapse within 5 years after EFS24EFS24

Living-donor intestinal transplantation is explicitly listed as not medically necessary. Services and related procedure codes for procurement or transplantation from a living donor will be denied when submitted for intestinal allotransplantation using a living-related donor segment.

Patients with distant metastatic disease for certain cancers are not eligible for transplantation. The policy identifies cutaneous squamous cell carcinoma, Merkel cell carcinoma, and malignant melanoma with distant metastasis as conditions that require oncology referral and states that candidates with distant metastasis are not eligible for transplantation.

Candidates with distant metastasis from skin cancers or melanoma are an absolute exclusion to transplant candidacy; the guidance requires oncology consultation for distant disease and designates distant metastasis as not eligible for transplantation. The policy also reiterates that living-donor intestinal transplantation is not covered.

Specific CPT/HCPCS codes describing living-donor donor enterectomy and living-donor intestinal allotransplantation are listed as not medically necessary (examples include 44133 and 44136 for living-donor enterectomy and living-donor intestinal allotransplantation, respectively). Providers should not expect coverage for procedures billed with these living-donor intestinal transplant codes.

Deceased-donor intestinal or multivisceral transplantation is considered not medically necessary when any absolute contraindication to transplantation is present. Examples of absolute contraindications include severe uncontrolled infection, multiorgan failure, nonresectable or disseminated malignancy, significant cardiopulmonary insufficiency, uncontrolled life‑threatening intra‑abdominal or systemic infections, and active AIDS unless strict HIV control criteria are met.

The policy lists several malignancy histories as absolute contraindications to transplantation. Examples include advanced or metastatic cancers referenced in the exclusions (for example, Stage IV disease and other specified metastatic conditions), which render an individual ineligible for intestinal or multivisceral transplantation until oncology guidance or contraindication resolution permits otherwise.

Active distant metastatic malignancy prior to transplantation is considered incompatible with transplant candidacy and is not eligible for transplantation. The document requires oncology assessment and treats active distant metastatic disease as an absolute contraindication.

Any stage III or IV melanoma is specified as not eligible for transplantation. Candidates with these stages should be referred for oncology evaluation and are excluded from transplant candidacy per the policy.

Procedure and Billing Codes

Covered CPT/HCPCS and Not Medically Necessary (living donor) procedure codesmixed

44132	Donor enterectomy (including cold preservation), open; from cadaver donor
44135	Intestinal allotransplantation; from cadaver donor
44137	Removal of transplanted intestinal allograft, complete
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
47133	Donor hepatectomy (including cold preservation), from cadaver donor
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
47144	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with trisegment split

1–10 of 24

1/3

HIV control criteria — transplant candidacy

CD4 count> 200 cells/mm3

HIV-1 RNAUndetectable viral load

Antiretroviral therapy (ART)Stable ART for > 3 months

HIV-associated complicationsAbsence of serious HIV‑associated complications (e.g., opportunistic infections)

EFS24 / PFS24

EFS24/PFS24 definitionEvent-free survival or progression-free survival assessed at 24 months

Use in hematologic malignancy guidance

Provider Requirements and Authorization

Prior Authorization

Transplant evaluation and program-level authorization

Transplant candidates require program-level evaluation and authorization. Prior authorization is required for intestinal and multivisceral transplantation; providers must document that the candidate has been evaluated by an accredited transplant program and that program-level approval/acceptance for listing or transplantation has been obtained.

Prior authorization must document program evaluation and acceptance for transplant listing or proceeding.
Retransplantation candidates must meet all eligibility criteria required for primary transplantation.
Living-donor intestinal transplantation is not covered and will be denied.

Billing Rule

Coding and claim documentation

Candidate Selection and Eligibility

Eligibility for Deceased-Donor Transplant

Candidate selection

Basic candidate requirements: Total irreversible intestinal failure plus one or more listed indications (see Initial and Repeat Transplant Indications); failure of medical and surgical rehabilitation and inability to achieve full enteral autonomy; in cases of prior malignancy, oncology clearance per published guidelines

Candidates for repeat transplant must meet same eligibility criteria as primary transplant

Candidate eligibility

Candidate selection considerations

Primary transplant candidacy: Intestinal transplantation is considered when intestinal failure is refractory to conventional management (including parenteral nutrition) or when complications occur such as progressive PN‑associated liver disease, recurrent sepsis, loss of central venous access, or extreme short‑bowel syndrome

Based on AST and AGA guidance

Absolute and Relative Contraindications

Absolute contraindications include severe uncontrolled infection, multiorgan failure, nonresectable or disseminated malignancy, significant cardiopulmonary insufficiency, advanced immunodeficiency (e.g., AIDS unless HIV control criteria are met), life‑threatening uncontrolled intra‑abdominal or systemic infections, and demonstrated patient noncompliance. These conditions preclude candidacy for intestinal or multivisceral transplantation.

Relative contraindications that may negatively affect survival and should be considered during candidate evaluation include ongoing substance abuse (including tobacco, alcohol, and narcotics), profound neurologic disabilities, severe congenital or acquired immunologic deficiencies, multisystem autoimmune diseases, progressive neuropathy or myopathy not amenable to rehabilitation, active uncontrolled medical processes likely to cause end‑organ damage, advanced age, and a positive crossmatch.

Active distant metastatic malignancy is explicitly listed among the absolute contraindications to intestinal and multivisceral transplantation. Retransplantation candidates must likewise have no absolute contraindications; individuals with active distant metastatic disease are not eligible for repeat transplant.

Distant metastatic disease from skin cancers or melanoma is treated as an absolute contraindication to transplantation. The policy directs referral to oncology for distant disease and states that such patients are not eligible for transplant candidacy.

Pretransplant Evaluation and Documentation

Documentation Required

Document failure of intestinal adaptation and prior rehabilitation attempts

A full pretransplant evaluation must document failure of intestinal adaptation, prior medical and surgical rehabilitation attempts, TPN dependence, and presence of complications such as TPN-associated liver disease, loss of central venous access, recurrent sepsis, dehydration, or high risk of death.

Include objective evidence of inability to achieve full enteral autonomy and specifics of prior rehabilitation efforts.
Document TPN dependence and related complications when applicable to support medical necessity.

Documentation Required

Document oncology clearance and cancer-specific wait times per Appendix

Pretransplant oncology evaluation must include documented adherence to cancer-specific wait times and recommendations (e.g., for colon, prostate, bladder, gynecologic, lung and skin cancers) as summarized in the Appendix.

Record the specific recommended wait-time interval for the candidate's prior cancer type and risk level from the Appendix.

Transplant Center and Program Standards

Note

Follow Cigna or delegated vendor authorization and claims procedures

Coverage applies to services administered by Cigna Companies; delegated vendor guidelines may be used in certain markets — ensure authorization and claims follow the applicable Cigna or delegated vendor process.

Verify whether the member's market uses Cigna-administered review or delegated vendor guidelines and submit accordingly.

Note

Refer living-donor intestinal transplant cases to experienced specialized centers

Due to the rarity of living-donor intestinal transplantation and implications in the literature, refer living-donor cases to centers with demonstrated experience and specialized processes.

Document center expertise when proposing living-donor procedures, recognizing no US living-donor cases have been reported since 2017.

Note

Ensure specialized center capability for intestinal/multivisceral transplantation

Post-Transplant Care and Follow-up

Comprehensive transplant services (per S2152)

Scope of S2152Global/service-level definition covering procurement, transplantation, and related complications

Included servicesDrugs, supplies, hospitalization with outpatient follow-up, medical/surgical, diagnostic, emergency, and rehabilitative services

Payment modelS2152 describes a global payment definition for complete or segmental solid organ procurement and transplantation

Long-term follow-up and care

Follow-up responsibilityLong-term follow-up and care per transplant center protocols and registry guidance

Outcome reportingRegistry and literature report graft and patient survival outcomes post-transplant

Key Definitions and Abbreviations

Irreversible gastrointestinal system failure — definition

DefinitionInability to maintain nutrition or adequate fluid and electrolyte balance without special support when available medical/surgical treatments fail to improve intestinal adaptation and gut function.

ContextApplies when total parenteral nutrition (TPN) fails or causes life‑threatening complications

Clinical implicationsIndication for intestinal or multivisceral transplantation after failed rehabilitation attempts

Multivisceral transplantation — definition

DefinitionEn bloc or composite transplantation involving stomach, liver, duodenum, pancreas and intestine (full) or modified based on organs replaced.

Indication

Background and Clinical Context

Intestinal, liver‑intestinal, and multivisceral transplantation are therapeutic options for selected patients with irreversible intestinal or multivisceral failure, typically when total parenteral nutrition (TPN) fails or causes life‑threatening complications. Indications include TPN failure or intolerance with complications (for example, progressive PN‑associated liver disease, loss of central venous access, recurrent sepsis), severe short bowel syndrome, pseudo‑obstruction, or a high risk of death related to intestinal failure.

Policy Revision History

2026-03-15policy_revisionLatest

Added material policy statements operationalizing guidance for candidates with a history of malignancy and added a policy statement specifying non-coverage of living-donor intestinal transplantation; effective date 2026-03-15.

Policy Summary

PayerCigna

PolicyIntestinal and Multivisceral Transplantation

Policy CodePolicy 0288

Change TypeMaterial modifications (malignancy guidanceliving-donor non-coverage)

Effective DateMar 15, 2026

Next Review DateDec 15, 2026

Key ActionObtain program-level transplant evaluation and oncology clearance and document required wait times for candidates with prior malignancy.

SourceLink

On This Page

Any stage III/IV melanoma is an exclusion to transplant candidacy

Consider relapse risk when evaluating candidacy

Burkitt lymphoma: EFS24 achieved; time interval to transplant = 2 years; very low relapse after EFS24EFS24

Hodgkin lymphoma: EFS24 achieved; time interval to transplant = 2 years; PET‑negative patients after initial treatment have low relapse riskEFS24

Approximately 10% relapse at 10 years after EFS24

Monoclonal B cell lymphocytosis: No wait time required prior to transplantation

Chronic lymphocytic leukemia (CLL): Consider transplant 2–3 years after treatment when in remission and absence of high‑risk features (e.g., CLL‑IPI score >4)

Assess remission status and prognostic indices

EFS24/PFS24 used as the milestone after which many lymphomas are considered for transplant timing

Typical interval24 months (EFS24/PFS24)

Claims will be adjudicated only when submitted with the most appropriate covered diagnosis and procedure codes. Services billed without a covered code under this Coverage Policy will be denied as not covered. Providers must submit complete documentation to support medical necessity and coding, including operative reports, donor/recipient procedure documentation, and global care details when applicable.

Use current, appropriate CPT/HCPCS/ICD-10 codes as of the date of service.
Claims submitted without covered procedure or diagnosis codes under this policy will be denied.
Include operative reports, transplant program acceptance, and perioperative documentation with prior authorization and claims.

Prior Authorization

Prior authorization: malignancy history & living-donor exclusion

When an individual has a history of malignancy, prior authorization must include oncology clearance per published guidelines and documentation of adherence to recommended pretransplant wait times or evidence the candidate is not contraindicated for transplantation. Living-donor intestinal transplantation is considered not medically necessary and will be denied.

Oncology clearance must follow published SOT oncology guidelines (see Appendix) and include recommended wait times and treatment details.
Document that the candidate meets policy criteria for transplantation in the context of prior malignancy.
Living donor intestinal transplantation: Not medically necessary — will be denied.

Documentation Required

Required oncology history and treatment documentation

Documentation for candidates with a prior or current malignancy must include detailed oncology history and treatment records. Submit cancer type, stage at diagnosis, dates and types of therapy (surgery, chemotherapy, radiation, immunotherapy), margin status, lymph node evaluation (e.g., sentinel lymph node biopsy, lymph node dissection), recurrence history, surveillance plans, and oncology clearance notes specifying recommended wait times or rationale for transplantation.

Cancer stage and histology (including any high-risk features).
Specific treatments performed (wide local excision, lymph node dissection, adjuvant radiation therapy, systemic therapy) with dates.
Follow-up and surveillance documentation and the oncology clearance letter noting recommended wait time or exemption rationale.

Documentation Required

Prior conservative management required

Transplantation is appropriate only after failure of conservative management: candidates must have failed or be intolerant of medical and surgical rehabilitation and demonstrated inability of the bowel to adapt to permit full enteral autonomy. Prior authorization should evidence prior conservative management efforts, including parenteral nutrition trials and surgical attempts at rehabilitation when applicable.

Document attempts at medical management, nutritional support, and surgical rehabilitation prior to listing for transplant.
Evidence that total parenteral nutrition (TPN) has failed, is contraindicated, or not tolerated, or that the patient has life-threatening complications from TPN.
Include details such as duration of TPN dependence, complications (e.g., recurrent sepsis, liver dysfunction, loss of central venous access), and prior surgeries.

Note

Conservative management prior to transplantation

Consideration of alternatives to transplantation is required as part of candidate selection. Providers should document that conservative options, including optimized parenteral nutrition and surgical rehabilitation procedures, were considered and attempted when clinically appropriate per professional society guidance.

Professional society guidance (AST, AGA) supports transplantation only when intestinal failure is refractory to conventional management.
Record that alternatives and risks/benefits were discussed with the patient and transplant program.

Step Therapy

Step therapy not specified

This policy does not define a step therapy sequence. Instead, it specifies timing, eligibility criteria, documentation, and prior authorization requirements necessary for coverage decisions.

No step therapy or fail-first sequence beyond the requirement to demonstrate failure/intolerance of medical and surgical rehabilitation prior to transplantation.
Decisions are based on meeting the policy's clinical criteria and program-level authorization.

Retransplant candidacy: Candidate meets all primary transplant eligibility criteria and lacks absolute contraindications

OPTN/SRTR data indicate worse outcomes for retransplantation; careful selection required

Candidate criteria by malignancy

Candidate eligibility tied to cancer type, stage, treatment, and elapsed disease-free intervals.

Skin cancer candidates: Eligibility depends on lesion risk and stage: low‑risk SCC and in situ melanoma may proceed with no delay after appropriate excision; higher‑risk lesions require multi‑year waits per guidance (see pretransplant skin cancer criteria); distant metastasis excludes candidacy

Documentation should include tumor stage, pathology, SLN status, and treatment details

Hematologic malignancy candidates: Many lymphomas and hematologic malignancies require achievement of EFS24/PFS24 with a typical time interval of 2 years prior to transplantation; monoclonal B cell lymphocytosis requires no wait; CLL commonly requires 2–3 years after treatment if in remissionEFS24/PFS24 where noted

Oncology consultation and documentation of relapse‑free interval required

Attach oncology consultation notes confirming clearance per published guidance.

Documentation Required

Include tumor staging, pathology, SLN status, PET imaging in pretransplant workup

Pretransplant oncologic workup documentation should include tumor staging, pathology reports, sentinel lymph node biopsy status when applicable, PET imaging results as appropriate, and oncology consultation notes for higher-stage or metastatic disease.

Provide pathology and staging documentation (e.g., SLN biopsy status) to support eligibility and wait-time decisions.
Include imaging (PET) and oncology recommendations when indicated by tumor type or stage.

Specialized transplant center experience is implied as necessary for intestinal and multivisceral transplantation given complexity and rarity; ensure programs have appropriate processes for evaluation and management.

Include evidence of center capability and specialized protocols in program-level authorizations.

Documentation Required

Provide center accreditation/OPTN outcome information when requested

The policy references transplant center standards and OPTN policies in its references, implying standard accreditation and registry-based outcome expectations apply; include relevant center accreditation or OPTN-aligned documentation when requested.

Provide OPTN/SRTR outcome context or center accreditation information if requested during review.

Retransplantation outcomesRetransplantation outcomes are generally worse than primary transplants but may be performed with careful selection

Oncologic follow-up — in situ melanoma

In situ melanoma managementWide local excision

Wait time before transplantationNo wait necessary for in situ melanoma

Posttransplant follow-upFollow-up posttransplantation at 3 months

Used for irreversible failure of multiple abdominal visceral organs when replacement of multiple digestive units is required

Procedure variantsFull multivisceral vs modified procedures transplanting one or two organs as indicated by pathology

Retransplantation — definition

DefinitionRepeat intestinal or multivisceral transplantation performed after prior graft loss.

Causes of graft lossAcute or chronic rejection, PTLD, graft dysfunction/dysmotility, severe infection, arterial graft aneurysm, or allograft liver failure

Candidate requirementRetransplant candidates must meet all eligibility criteria for primary transplantation and have no absolute contraindications

Living-donor intestinal transplantation — definition

DefinitionSmall bowel transplantation using a segment from a living-related donor.

FrequencyRare practice; 44 procedures in the U.S. over 20 years with no U.S. cases since 2017

Policy stanceLiving-donor intestinal transplantation is considered not medically necessary per policy statements

EFS24 / PFS24 — definition

DefinitionEvent-free survival / progression-free survival assessed at 24 months (EFS24/PFS24)

Use in guidanceServes as the milestone after which many hematologic malignancies are considered for transplant timing

Typical timepoint24 months

Abbreviations for treatment modalities

ARTAdjuvant radiation therapy

SLNSentinel lymph node (biopsy)

Common abbreviationsART = adjuvant radiation therapy; SLN = sentinel lymph node