ModifiedHealth NetPolicy CP.MP.58

Intestinal and Multivisceral Transplant

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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

PayerHealth Net

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeMaterial revisions to contraindications, added retransplantation criteria, and coding updates

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating indication (II.A) and absence of contraindications (II.B); include evidence for retransplantation when applicable.

SourceLink

POLICY UPDATE CHANGES

Updated contraindication glomerular filtration rate threshold and expanded HIV-related requirements and substance use language.

Added retransplantation criteria and new CPT codes (44137, 48554).

Updated GFR threshold in Criteria II.B.3. from < 30 mL/min/1.73m2 to < 40 mL/min/1.73m2.

Added criteria under II.A.6–II.A.7. for large desmoid tumors.

Removed Criteria II.B.5., II.B.6., and II.B.12. (certain prior contraindications) from the policy.

Clarified wording in multiple criteria for clarity and terminology updates.

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ModifiedHealth NetPolicy CP.MP.58

Intestinal and Multivisceral Transplant

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Policy Summary

PayerHealth Net

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeMaterial revisions to contraindications, added retransplantation criteria, and coding updates

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating indication (II.A) and absence of contraindications (II.B); include evidence for retransplantation when applicable.

SourceLink

POLICY UPDATE CHANGES

Updated contraindication glomerular filtration rate threshold and expanded HIV-related requirements and substance use language.

Added retransplantation criteria and new CPT codes (44137, 48554).

Updated GFR threshold in Criteria II.B.3. from < 30 mL/min/1.73m2 to < 40 mL/min/1.73m2.

Added criteria under II.A.6–II.A.7. for large desmoid tumors.

Removed Criteria II.B.5., II.B.6., and II.B.12. (certain prior contraindications) from the policy.

Clarified wording in multiple criteria for clarity and terminology updates.

3transplant procedure types

10contraindication items

7indications listed

~20codes referenced

GFR <40renal threshold

Addedretransplant criteria

Coverage Criteria for Intestinal and Multivisceral Transplantation

inv-01: Initial transplant medical necessity

Covered when ALL of the following are met

Overall

Procedure types: Isolated intestinal transplant OR combined intestinal and liver transplant OR multivisceral transplant as defined in I.A-C.
Indications (II.A)
- TPN failure: Failure of total parenteral nutrition (TPN) as shown by one or more of: impending or overt TPN-induced liver injury (elevated bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastro-esophageal varices, coagulopathy, stomal bleeding, or hepatic fibrosis/cirrhosis); thrombosis of two or more central veins; two or more hospitalizations per year for systemic sepsis due to line infection; one episode of septic shock, acute respiratory distress syndrome, and/or line-related fungemia; frequent severe dehydration despite IV fluids in addition to TPN; other complications leading to loss of vascular access.
- High risk of death if transplant is not performed.
- Severe short bowel syndrome (gastrostomy, duodenostomy, and/or residual small bowel <10 cm in infants or <20 cm in adults).
- Frequent hospitalizations for complications directly related to intestinal failure (e.g., opioid dependency for pain management, pseudoobstruction).
- Portomesenteric cirrhosis: Significant hepatic cirrhosis associated with diffuse portomesenteric thrombosis.
- Tumors or congenital disorders: Large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure; congenital secretory diarrheal disorders.

inv-02: Retransplantation

Retransplantation covered when ALL initial transplant criteria are met and one of the following is present

Retransplantation

Retransplant indications for retransplant: One of the following must be present: graft failure following primary small bowel, small bowel-liver, or multivisceral transplantation due to technical complications or acute rejection; OR graft failure attributable to chronic rejection or recurrence of the primary disease.

inv-03: Summary of criteria updates

Policy includes candidate criteria, new indications for large desmoid tumors, and retransplantation criteria; specific logical nodes not present in this excerpt

updates: Criteria revised and removed as noted in the revision history (including GFR threshold change, wording updates, and removals of certain contraindications).GFR < 40 mL/min/1.73m2

Full criteria logic and some detailed nodes are located in other sections of the policy not included in this excerpt.

The procedure is considered not indicated when the member/enrollee meets any of the contraindications listed in Section II.B. These include, but are not limited to, malignancy with high risk of recurrence or death and other severe uncontrolled medical condition expected to limit survival after transplant. Providers should confirm that none of the II.B contraindications apply when requesting authorization for intestinal, combined intestinal–liver, or multivisceral transplantation.

The policy revision removed and revised several specific exclusion items; for example, Criteria II.B.5 and II.B.6 were removed in the latest edits. The full, prior exclusion text and the exact removed items are not present in this excerpt, so providers should rely on the current II.B list in the policy document for the operative contraindications used in coverage determinations.

Per professional guidance cited in the policy, intestinal transplantation solely for continued dependence on TPN without life-threatening TPN‑related complications is not recommended. The AST position specifically states transplantation should be reserved for TPN‑dependent patients who have or are likely to develop life‑threatening TPN‑related complications (for example, liver disease, recurrent sepsis, or threatened loss of central venous access).

Additional clarifications and wording changes were made in the revision history (for example, terminology updates such as 'post‑mesenteric' to 'portomesenteric' and other editorial edits). The excerpt does not provide the full list of these ancillary clarifications; refer to the policy text for the complete, current wording.

Candidate Eligibility Criteria

inv-26: Candidate criteria

Candidate must meet indications and lack contraindications

Candidate selection: Member/enrollee must have irreversible intestinal failure and meet at least one indication in II.A and have none of the contraindications in II.B.

inv-27: Notable candidate criteria updates

New and revised candidate criteria are included; excerpt documents additions for desmoid tumors and adjustments to renal threshold

renal_function: Glomerular filtration rate (GFR) contraindication threshold was updated: GFR < 40 mL/min/1.73m2 is listed as a contraindication unless being considered for multi-organ transplant.< 40 mL/min/1.73m2

Revision history documents this change and related candidate criteria edits.

Contraindications That May Preclude Transplant

B. Does not have ANY of the following contraindications:

1. Malignancy with high risk of recurrence or death related to cancer;

2. Other severe uncontrolled medical condition expected to limit survival after transplant;

3. Glomerular filtration rate < 40 mL/min/1.73 m2 unless being considered for multi-organ transplant;

4. HIV infection with detectable viral load unless all of the following are noted:

a. CD4 cell count >200 cells/mm3;

b. Absence of active AIDS-defining opportunistic infection or malignancy;

c. Member/enrollee is currently on effective ART (antiretroviral therapy);

5. Septic shock;

6. Progressive cognitive impairment;

7. Stroke, acute coronary syndrome, or myocardial infarction (excluding demand ischemia) within 30 days;

8. Chronic infection with highly virulent and/or resistant microbes that are poorly controlled pre-transplant;

9. Inability to adhere to the regimen necessary to preserve the transplant, even with caregiver support;

10. 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 (unless urgent transplant timelines are present, in which case a commitment to reducing behaviors is acceptable). Serial blood and urine testing may be used to verify abstinence from substances that are of concern.

Pre-Transplant Evaluation Requirements

Documentation Required

Required pre‑transplant evaluation documentation

Pre-transplant evaluation must document TPN-related complications, vascular access status, history of infection/sepsis including hospitalizations, hepatic status, renal function, and behavioral/substance use assessment as relevant to indications and contraindications.

Document evidence of TPN-induced liver injury (e.g., elevated bilirubin/liver enzymes, splenomegaly, thrombocytopenia, varices, coagulopathy, stomal bleeding, fibrosis/cirrhosis).
Document thrombosis of central veins, number/locus of hospitalizations for line-related sepsis, episodes of septic shock/ARDS/fungemia, and loss of vascular access.
Include hepatic and renal function assessments (note GFR threshold), and behavioral/substance use evaluation per contraindication guidance.

Note

Additional evaluation details

Additional evaluation details are not included in this excerpt; follow the full policy for complete pre‑transplant assessment requirements.

Coding and Billing Guidance

Covered CPT CodesCPT

44135	Intestinal allotransplantation; from cadaver donor.
44136	Intestinal allotransplantation; from living 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.
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.
47145	Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation; with lobe split.

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1/2

HCPCS Codes / Global procurementHCPCS

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 organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including drugs, supplies, hospitalization, and outpatient follow-up.

Added CPT CodesCPT

44137	Addition noted in policy (Removal of transplanted intestinal allograft, complete).
48554	Addition noted in policy (Transplantation of pancreatic allograft).

inv-11: 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 contextListed as criterion for severe short bowel syndrome indication for transplant

inv-12: Glomerular filtration rate (GFR) — <40 mL/min/1.73m2 (contraindication)

GFR contraindication threshold<40 mL/min/1.73m2

ExceptionMay not apply if being considered for multi-organ transplant (per policy text)

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization required; affected CPT/HCPCS codes listed

Prior authorization is required for the listed intestinal, combined, and multivisceral transplant procedures and related services; the policy provides the applicable CPT and HCPCS codes for claim and coding reference.

Examples of referenced CPT codes include 44135, 44136, 44137, 44715, 44720, 44721, 47135, 47143–47147, 48554.
HCPCS/global codes referenced include S2053, S2054, S2055, and S2152.

Prior Authorization

Prior authorization includes newly added CPT codes and retransplantation criteria

Prior authorization requirements apply consistent with the updated candidate and retransplantation criteria and include the newly added CPT codes noted in the policy.

Newly added CPT codes called out in the revision include 44137 and 48554 and should be included in authorization requests when applicable.
Retransplantation requests must meet initial transplant criteria plus retransplantation indications per Section III.

Post-Transplant Coverage and Related Codes

inv-34: Procurement, transplantation, and related complications/global care — Global codes (e.g., S2152) describe bundled procurement, transplantation, and related pre- and post-transplant care; specific post-transplant coverage rules not fully listed here

Global procurement/transplant code exampleS2152 — Solid organ(s), procurement, transplantation, and related complications; global definition including pre- and post-transplant care

HCPCS examplesS2053, S2054, S2055 — small intestine/liver, multivisceral transplant, and harvesting multivisceral organs

Scope noteGlobal codes describe bundled procurement, transplantation, and related pre- and post-transplant care; specific post-transplant coverage rules are not fully listed in this excerpt

inv-35: retransplantation — Retransplantation criteria were added under Section III; specific post-transplant coverage rules not included in this excerpt

Retransplantation addedRetransplantation criteria were added under Section III of the policy

Background and Scope

Intestinal transplantation is a therapeutic option for patients with irreversible intestinal failure due to severe primary gastrointestinal disease or short bowel syndrome (SBS). The policy defines transplant types — isolated intestinal, combined intestinal–liver, and multivisceral — and lists indications including failure of TPN, severe SBS with residual small bowel <10 cm in infants or <20 cm in adults, portomesenteric‑associated cirrhosis, and large intra‑abdominal tumors with expectation of cure.

Key Definitions

inv-23: SBS — Short bowel syndrome (definition and context)

Definition — SBSShort bowel syndrome (SBS): loss of absorptive capacity of the small bowel leading to intestinal failure

Typical remaining length referenceSBS generally occurs when approximately <200 cm of small bowel remains

Relevance to transplantSBS with severe functional loss may be an indication for intestinal transplantation

inv-24: Multivisceral transplant — Includes stomach, duodenum, pancreas, liver, small intestine, large intestine; modified versions may exclude liver

Definition — Multivisceral transplantIncludes stomach, duodenum, pancreas, liver, small intestine, and large intestine

Modified versionA modified multivisceral transplant may exclude the liver if the recipient's liver is normal

Center and Program Requirements

Note

Center requirements: specialist review; no FACT/volume requirements specified

The policy was reviewed by surgical transplant specialists; this document does not specify FACT accreditation or minimum procedural volume requirements for centers.

Providers should reference facility credentialing/accreditation requirements per their payer network separately, as the policy itself does not impose explicit FACT or volume standards.

Note

Center requirements: additional notes

Additional center requirement notes are not specified in the provided excerpt; follow contractual network and accreditation requirements in addition to this policy.

Refer to payer network or credentialing guidance for any center-specific operational requirements.

Revision History and Policy Changes

05/24revised

Expanded HIV-related criteria (CD4 >200 and ART requirement) and updated GFR wording; GFR threshold documented in revision notes (updated previously between 05/22–04/25).

05/23revised

Updated substance use contraindication language to explicitly include tobacco, vaping, marijuana, and allowances for commitments when urgent transplant timelines exist.

05/22revised

Policy Summary

PayerHealth Net

PolicyIntestinal and Multivisceral Transplant

Policy CodePolicy CP.MP.58

Change TypeMaterial revisions to contraindications, added retransplantation criteria, and coding updates

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation demonstrating indication (II.A) and absence of contraindications (II.B); include evidence for retransplantation when applicable.

SourceLink

On This Page

Denial Risk

Contraindications may trigger denial

inv-20: Contraindications may trigger denial — Presence of any listed contraindication (e.g., malignancy with high risk of recurrence, GFR below threshold, uncontrolled severe medical conditions) may lead to denial

Presence of any listed contraindication may lead to denial of transplant approval.
Providers should document current status and any mitigating factors (e.g., control of HIV on ART, demonstrated substance-use risk reduction) when submitting prior authorization requests.

Refer to the full policy for other required assessments and specific documentation formats.

PlacementListed under contraindications (II.B.3) for transplant candidate selection

inv-13: GFR cutoff — < 40 mL/min/1.73m2 (restatement)

Restated GFR cutoff< 40 mL/min/1.73m2

Revision noteGFR updated from prior lower threshold to <40 mL/min/1.73m2 in Criteria II.B.3.

Policy locationReferenced in candidate contraindications section (II.B.3)

Note

Provider action: submit required authorization materials

Providers must follow the policy's provider action requirements when submitting authorization requests; see full policy for the specific action items.

Submit complete clinical documentation demonstrating indications and absence of contraindications per Sections II.A and II.B.

Note

Provider action: follow policy instructions

Additional provider action notes and operational steps are described in the full policy; providers should consult the policy for detailed instructions on submission and review processes.

Follow updated criteria and code lists when preparing authorization packages.

Documentation Required

Required documentation to support medical necessity

Documentation submitted to support medical necessity must show the member/enrollee meets at least one indication in II.A and does not have any contraindication listed in II.B; for retransplantation, documentation must also demonstrate graft failure for an approved reason.

Include clinical evidence for the specific indication (e.g., TPN complications, residual bowel length, episodes of sepsis, hepatic cirrhosis with portomesenteric thrombosis, tumor details).
For retransplantation, include documentation of prior graft failure due to technical complications, acute rejection, chronic rejection, or recurrence of primary disease.

Documentation Required

Provider action: be prepared to supply supplemental documentation

Additional provider documentation items may be required by the payer during review; consult the full policy or payer instructions for any supplemental requirements.

Be prepared to provide serial blood/urine testing results when substance use abstinence must be verified.

Note

Provider note: revised/removed criteria may affect approvals

Removal and revision of prior criteria (for example, changes to contraindications and GFR thresholds) may affect past approval patterns; providers should ensure current documentation aligns with the revised policy when requesting authorization.

Notable changes include raising the GFR cutoff to <40 mL/min/1.73m2 and removing certain prior contraindications (e.g., absence of adequate support system).

Coverage requirementRetransplantation covered when all initial transplant criteria are met plus one of the retransplant indications (e.g., graft failure due to technical complications, acute or chronic rejection)

Post-transplant rulesSpecific post-transplant coverage rules for retransplantation are not included in this excerpt

Occasional additionA kidney transplant is occasionally included if the recipient has end-stage renal disease

inv-25: portomesenteric — Portomesenteric thrombosis referenced in criteria wording change (previously 'post-mesenteric')

Term updatedPolicy wording changed from 'post-mesenteric' to 'portomesenteric' in Criteria II.A.2.5

ContextPortomesenteric thrombosis referenced in candidate criteria related to hepatic cirrhosis indication

Source noteChange recorded in policy revision history and reflected in criteria text

Edited contraindications to add multiple items (including GFR restriction, HIV with detectable viral load, stroke/ACS/MI, septic shock, progressive cognitive impairment) and updated GFR wording in the contraindications section.

04/25revisedLatest

Clarified multiple policy and criteria items (including TPN-induced liver injury language, 'peristomal'→'stomal', hospitalization requirement for sepsis criterion) and updated GFR cutoff to <40 mL/min/1.73m2; removed several criteria (II.B.5, II.B.6, II.B.12) and updated portomesenteric terminology.