CurrentHawaii Medical Service Association (HMSA)Policy MM.07.025

Small Bowel/Liver and Multivisceral Transplant

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Coverage and precertification for small bowel and liver transplantation, multivisceral transplantation, and retransplantation in pediatric and adult individuals with intestinal failure and related liver failure for inpatient services under HMSA HMO and PPO plans.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicySmall Bowel/Liver and Multivisceral Transplant

Policy CodePolicy MM.07.025

Change TypeNo material change

Effective DateOctober 24, 2025

Last ReviewSep 11, 2025

Next Review DateN/A

Key ActionObtain precertification for both the transplant evaluation and the transplant, submitting the request and required documentation by mail, fax, or iExchange.

SourceLink

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CurrentHawaii Medical Service Association (HMSA)Policy MM.07.025

Small Bowel/Liver and Multivisceral Transplant

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Sign up for Hawaii Medical Service Association (HMSA) Policy MM.07.025 alerts

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Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicySmall Bowel/Liver and Multivisceral Transplant

Policy CodePolicy MM.07.025

Change TypeNo material change

Effective DateOctober 24, 2025

Last ReviewSep 11, 2025

Next Review DateN/A

Key ActionObtain precertification for both the transplant evaluation and the transplant, submitting the request and required documentation by mail, fax, or iExchange.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>200 cells/mm³Minimum CD4 count

>6 monthsCD4 duration

UndetectableRequired HIV-1 RNA

>3 monthsStable antiretroviral therapy

10/yearApproved center volume

65%1-year center survival

Covered Transplant Services

Primary small bowel/liver or multivisceral transplant

Covered when all of the following are met:

Primary transplant eligibility: The individual is pediatric or adult, has intestinal failure characterized by loss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance, has been managed with long-term total parenteral nutrition (TPN), and has developed impending end-stage liver failure.

Coverage is subject to Administrative Guidelines.

Retransplantation

Covered after failure of the primary transplant:

Retransplant eligibility: The individual has had a failed primary small bowel/liver transplant or multivisceral transplant and is being considered for small bowel/liver retransplantation or multivisceral retransplantation.

Coverage is subject to Administrative Guidelines.

HIV-positive candidate criteria

HIV-positive individuals may be considered when all of the following are met:

HIV-positive candidate criteria: The individual has a CD4 count greater than 200 cells per cubic millimeter for more than 6 months; HIV-1 RNA is undetectable; the individual has been on stable antiretroviral therapy for more than 3 months; no other complications from AIDS are present; and all other transplantation criteria are met.CD4 >200 cells/mm³ for >6 months; HIV-1 RNA undetectable; stable antiretroviral therapy >3 months

Examples of AIDS complications include opportunistic infection, aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi sarcoma, and other neoplasm.

General candidate requirements

The candidate must meet all of the following general requirements:

General transplant requirements: The individual has adequate cardiopulmonary status and documented compliance with medical management.

Small bowel transplant to avoid progression to end-stage liver failure

A small bowel transplant in the setting of progressive liver failure may be considered when intolerance of chronic TPN is demonstrated. Evidence includes, but is not limited to:

Evidence of TPN intolerance

TPN-related complications: Multiple and prolonged hospitalizations to treat TPN-related complications.
Progressive reversible liver failure: Development of progressive but reversible liver failure.

Medicare-referenced intestinal transplantation

Medicare-referenced coverage applies when all of the following are met:

Medicare intestinal transplantation criteria

Clinical and center requirements: The patient has irreversible intestinal failure; the patient has failed total parenteral nutrition; and the procedure is performed at an approved center.
Approved-center criteria are a volume of 10 intestinal transplants per year with a 1-year survival rate of 65 percent.

AGA-referenced intestinal transplant indications

AGA-referenced indications include any of the following in the setting of life-threatening complications due to intestinal failure or long-term TPN:

AGA-referenced indications

Impending liver failure
Central venous thrombosis: Thrombosis of major central venous channels
Central line-associated sepsis: Frequent central line-associated sepsisFrequent
Severe dehydration: Frequent severe dehydrationFrequent

Coverage is limited by malignancy and other high-risk clinical conditions. Contraindications include known current malignancy, including metastatic cancer; recent malignancy with a high risk of recurrence; a history of cancer with a moderate risk of recurrence; systemic disease that could be exacerbated by immunosuppression; untreated systemic infection, including chronic infection, that makes immunosuppression unsafe; other irreversible end-stage disease not attributed to intestinal failure; and psychosocial conditions or chemical dependency that affect adherence to therapy.

HIV-positive candidates must have no other AIDS-related complications and must satisfy all other transplantation criteria. Excluding complications include opportunistic infection, aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infection, Kaposi sarcoma, and other neoplasm.

Small bowel/liver or multivisceral transplantation is not covered in situations outside the policy’s covered indications because improvement in health outcomes is not established.

Applicable Codes and HIV Thresholds

Covered CPT CodesCPTCovered

44120	Enterectomy, resection of small intestine; single resection and anastomosis.
44121	Enterectomy, resection of small intestine; single resection and anastomosis; each additional resection and anastomosis.
44132	Donor enterectomy (including cold preservation), open; from cadaveric donor.
44133	Donor enterectomy (including cold preservation), open; from cadaveric donor; partial, 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, venous anastomosis, each; arterial anastomosis, each.
44799	Unlisted procedure, intestine.
47133	Donor hepatectomy (including cold preservation), from cadaver donor.
47135	Liver allotransplantation, orthotopic, partial or whole, cadaver or living donor, any age.

1–10 of 19

1/2

Covered HCPCS CodesHCPCSCovered

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.

Covered ICD-10-CM CodesICD-10Covered

K72.00-	Acute and subacute hepatic failure code range.
K72.01	Acute and subacute hepatic failure code.
K72.10-	Chronic hepatic failure code range.
K72.11	Chronic hepatic failure code.
K91.2	Postsurgical malabsorption, not elsewhere classified (includes short bowel syndrome).

Covered ICD-10-PCS CodesICD-10Covered

0DY60Z0	Transplantation, stomach, open, allogeneic.
0DY80Z0	Transplantation, small intestine, open, allogeneic.
0DYE0Z0	Transplantation, large intestine, open, allogeneic.
0FY00Z0	Transplantation, liver, open, allogeneic.
0FYG0Z0	Transplantation, pancreas, open, allogeneic.

HIV-positive candidate threshold

CD4 count>200 cells per cubic millimeter for greater than 6 months

HIV-positive candidate threshold

HIV-1 RNAUndetectable

HIV-positive candidate threshold

Stable antiretroviral therapy>3 months

Precertification and Documentation

Prior Authorization

Precertification Required for Evaluation and Transplant

Precertification is required for both the transplant evaluation and the transplant itself. The proposed treating facility must submit the precertification request.

Applies to small bowel/liver and multivisceral transplant evaluation.
Applies to the transplant procedure itself.

Documentation Required

Precertification Documentation

To request precertification, complete HMSA's Precertification Request and submit it with the required clinical documentation through an approved channel.

Mail the completed request.
Fax the completed request.
Use iExchange as indicated by HMSA.

Transplantation Overview

Small bowel/liver transplantation combines an intestinal allograft with a liver allograft. The graft may include the small bowel and liver alone or additional organs such as the stomach, duodenum, jejunum, ileum, pancreas, or colon. It is used for intestinal failure, commonly associated with short bowel syndrome, when long-term total parenteral nutrition has caused or is causing severe liver complications. Multivisceral transplantation is considered when anatomic or other medical problems preclude a small bowel/liver transplant.

Key Terms

Definition

Short bowel syndromeAn inadequate absorbing surface of the small intestine caused by extensive disease or surgical removal of a large portion of the small intestine.

Definition

Intestinal failureLoss of absorption with inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.

Definition

Small bowel/liver transplantationTransplantation of an intestinal allograft together with a liver allograft, either alone or with one or more of the stomach, duodenum, jejunum, ileum, pancreas, or colon.

Definition

Candidate Eligibility Pathways

Primary small bowel/liver or multivisceral transplant candidate

Covered for pediatric and adult individuals when all of the following are met:

Primary transplant candidate: The individual has intestinal failure characterized by impaired absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance; has been managed with long-term TPN; and has developed impending end-stage liver failure.

Coverage is subject to Administrative Guidelines.

Retransplant candidate

Retransplantation is covered after a failed primary transplant when all of the following are met:

Retransplant candidate: The primary small bowel/liver or multivisceral transplant has failed; the individual continues to meet transplantation criteria; and no contraindication is present that would make retransplantation futile or likely to significantly worsen a comorbid condition.

The policy identifies retransplantation as contraindicated when it is expected to be futile because of comorbid disease or when post-transplant care would significantly worsen comorbid conditions.

Contraindications and Exclusions

Transplantation may be contraindicated by known current or metastatic malignancy; recent malignancy with high recurrence risk; prior cancer with moderate recurrence risk; nonresectable malignancy; systemic disease worsened by immunosuppression; untreated systemic or chronic infection that makes immunosuppression unsafe; AIDS-related complications such as opportunistic or resistant fungal infection, Kaposi sarcoma, or other neoplasm; other irreversible end-stage disease not caused by intestinal failure; comorbid disease that makes transplantation futile or significantly worsens with post-transplant care; profound neurologic disabilities; life-threatening comorbidities; severe immunologic deficiencies; autoimmune disease; insufficient vascular patency; or psychosocial conditions or chemical dependency that impair adherence to therapy.

Evaluation and Precertification Requirements

Documentation Required

Complete the transplant evaluation requirements

Before proceeding with the transplant evaluation, obtain precertification through HMSA’s Precertification Request; the proposed treating facility must submit it by mail or fax, or through iExchange. The evaluation should document intestinal failure, long-term TPN management, and impending end-stage liver failure for primary transplantation, or failure of the prior transplant for retransplantation.

Assess adequate cardiopulmonary status.
Document compliance with medical management.
For retransplantation, assess for contraindications.

Transplant Center Requirements

Note

Verify the transplant center meets volume and survival criteria

Use an approved center that performs 10 intestinal transplants per year and has a 1-year survival rate of 65 percent, as referenced by Medicare.

Minimum intestinal transplant volume: 10 per year.
1-year center survival criterion: 65 percent.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicySmall Bowel/Liver and Multivisceral Transplant

Policy CodePolicy MM.07.025

Change TypeNo material change

Effective DateOctober 24, 2025

Last ReviewSep 11, 2025

Next Review DateN/A

Key ActionObtain precertification for both the transplant evaluation and the transplant, submitting the request and required documentation by mail, fax, or iExchange.

SourceLink

On This Page

Documentation Required

Clinical Eligibility Documentation

Document that the individual meets the clinical eligibility requirements for covered small bowel/liver or multivisceral transplantation. The policy also covers retransplantation after a failed primary transplant.

Intestinal failure characterized by loss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.
Management with long-term total parenteral nutrition (TPN).
Impending end-stage liver failure.
For retransplantation: a failed primary small bowel/liver transplant or multivisceral transplant.

Unsupported block type: documentation

Denial Risk

Contraindications and High-Risk Conditions

Coverage may be denied when contraindications or high-risk conditions make transplantation or immunosuppression unsafe or unlikely to produce an appropriate outcome.

Known current malignancy, including metastatic cancer.
Recent malignancy with high risk of recurrence.
History of cancer with a moderate risk of recurrence.
Systemic disease that could be exacerbated by immunosuppression.
Untreated systemic infection making immunosuppression unsafe, including chronic infection.
Other irreversible end-stage disease not attributed to intestinal failure.
Psychosocial conditions or chemical dependency affecting the individual's ability to adhere to therapy.

Denial Risk

Outside Covered Indications

Small bowel/liver or multivisceral transplantation is not covered in all other situations outside the policy criteria because it is not known to improve health outcomes.

Coverage is limited to the policy's stated indications and applicable Administrative Guidelines.

Denial Risk

HIV-Related Exclusions

Candidates with AIDS must have no other AIDS-related complications and must meet all other transplantation criteria.

Excluded complications include opportunistic infection such as aspergillus, tuberculosis, coccidioidomycosis, and resistant fungal infections.
Kaposi's sarcoma and other neoplasms are also identified as disqualifying complications.

Multivisceral transplantationA transplant including the small bowel and liver with one or more additional organs, used when anatomic or other medical problems preclude a small bowel/liver transplant.

Definition

Short bowel syndromeAn inadequate absorbing surface of the small intestine due to extensive disease or surgical removal of a large portion of the small intestine; it may be associated with liver failure related to long-term total parenteral nutrition.

Definition

Multivisceral transplantA transplant including the small bowel and liver with one or more of the stomach, duodenum, jejunum, ileum, pancreas, and/or colon.

Definition

Small bowel/liver transplantA transplant of the small bowel and liver without the additional organs included in a multivisceral graft.

Abbreviation

ITIntestinal transplantation.

Abbreviation

TPNTotal parenteral nutrition.

HIV-positive candidate

HIV-positive candidates must meet all of the following requirements:

HIV-positive transplant candidate: CD4 count is greater than 200 cells/mm³ for more than 6 months; HIV-1 RNA is undetectable; the individual has been on stable antiretroviral therapy for more than 3 months; no other AIDS-related complications are present; and all other transplant criteria are satisfied.CD4 >200 cells/mm³ for >6 months; HIV-1 RNA undetectable; antiretroviral therapy >3 months

AIDS-related complications include opportunistic infection, aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi sarcoma, and other neoplasm.

Retransplantation candidacy

Retransplantation may be considered when:

Continued retransplantation candidacy: The patient continues to meet criteria for transplantation.

The policy describes the available retransplantation evidence as limited, primarily from single-center case series and one UNOS database series.