CurrentKaiser PermanentePolicy N/A

Intestinal and Multi-Visceral Transplantation

Clinical review criteria governing referral, candidate selection, contraindications, and documentation requirements for intestinal and multivisceral transplantation for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyIntestinal and Multi-Visceral Transplantation

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateDec 2, 2025

Key ActionSubmit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3types described

3CPT codes listed

54-75% / 42-50%1-/5-yr survival

6 monthsabstinence period

Coverage Criteria for Intestinal and Multivisceral Transplantation

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Primary indication: Patient has irreversible Short Bowel Syndrome or intestinal failure with severe complications of TPN (e.g., lack of vascular access, recurrent central venous catheter-related infections, metabolic bone disease, or severe/progressive hepatic dysfunction)

Applies to pediatric and adult patients; combined transplant indicated when irreversible progressive chronic liver disease is present

inv-02: Contraindications and Relative Contraindications

Transplant referral/listing excluded or restricted when ANY of the following contraindications or relative contraindications are present:

Absolute contraindications: Uncontrollable active infection; advanced cardiopulmonary disease or other life-limiting disorders (excluding hepatopulmonary syndrome); inability to accept the procedure, understand its nature, or cooperate with the treatment protocol; irreversible brain damage or significant neurologic dysfunction; patients with hepatocellular carcinoma exceeding Region 5/UCSF criteria (exceptions may be considered for select hepatoblastoma cases)

Exceptions may be considered case-by-case for certain conditions

Relative contraindications: Renal failure (excluding hepatorenal syndrome); portal vein thrombosis; active infection outside the hepatobiliary system; advanced malnutrition; severe diabetic complications; multiple prior abdominal surgeries

These are relative and not necessarily absolute exclusions

Behavioral and social criteria: Candidates must be free from substance abuse and alcohol for six months with documented evaluation; thoracic organ candidates must be tobacco-free for six months; candidates must have adequate social support and demonstrate proven adherence to medical treatment6 months

Routine monitoring and exceptions may be made on a case-by-case basis

Evidence does not support routine replacement of long‑term TPN with intestinal transplantation. The MTAC review found no comparative studies between intestinal transplant and long‑term TPN; available literature consists of case series with limitations such as selection bias and lack of control groups. Reported survival after intestinal transplantation ranged from approximately 54% to 75% at 1 year and fell to about 42% to 50% at 5 years. Infection accounted for more than 40% of deaths in the reviewed series.

Because intestinal transplantation is currently used as a rescue therapy for patients who are TPN‑dependent and predicted to have poor survival on TPN, controlled trials comparing transplantation to TPN are unlikely and comparative evidence is lacking; consequently the procedure does not meet the Kaiser Permanente Medical Technology Assessment criteria for general replacement of TPN.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required

Prior authorization is required for the listed CPT codes. Verify pre-authorization requirements for the member's specific plan using the Pre-authorization Code Check prior to scheduling. Failure to obtain required prior authorization may result in claim denial or delayed payment.

Affected CPT codes: 44135 (intestinal allotransplantation; cadaver donor), 44136 (intestinal allotransplantation; living donor), 44137 (removal of transplanted intestinal allograft, complete)
Use the Pre-authorization Code Check to confirm authorization rules by plan type and obtain any required prior authorization/approval before the procedure

Documentation Required

Supporting evaluations and coverage verification

Obtain and submit supporting clinical evaluations and documentation to verify coverage and medical necessity. Incomplete documentation may delay review or result in denial.

Submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity
For candidates with prior malignancy, include oncologist consultation documenting recurrence risk and rationale for transplant candidacy
Document TPN history and rationale — intestinal transplant is intended for patients predicted to have poor survival on long-term TPN and is not an alternative to TPN
Include evidence of adequate social support, substance use evaluation (6 months free if applicable), tobacco abstinence if required by program, and ability/willingness to travel to a KP approved transplant Center of Excellence on short notice
Provide evaluations addressing contraindications (e.g., active uncontrollable infection, advanced cardiopulmonary disease, irreversible neurologic dysfunction)

Candidate Selection Criteria

inv-15: Candidate criteria

Candidate selection for intestinal and combined intestinal-liver transplantation:

Candidate must have: Irreversible Short Bowel Syndrome or intestinal failure and severe TPN-related complications, or irreversible progressive chronic liver disease for combined intestinal-liver transplant

Includes both pediatric and adult patients

Support and adherence: Demonstrated adequate social support systems and a proven record of adherence to medical treatment; caregiver(s) available and able to travel on short notice to the KP-approved transplant center

Patient and caregiver willingness and ability to travel on short notice required

Evaluation and documentation: Necessary evaluations completed with documentation submitted (including the last 6 months of clinical notes) and oncology consultation when prior malignancy exists to assess recurrence risk

Consult oncologist for patients with prior malignancy to determine suitability

Behavioral prerequisites: No uncontrolled active infection; free from substance abuse and alcohol for six months with program evaluation when applicable; thoracic candidates tobacco-free for six months6 months

Exceptions may be considered on a case-by-case basis

Absolute and Relative Contraindications

Uncontrollable active infection is an absolute contraindication to transplantation and may result in denial of coverage until the infection is controlled. Candidates with ongoing, uncontrolled infections are not appropriate for referral or listing.

Advanced cardiopulmonary disease or other life‑limiting disorders (excluding hepatopulmonary syndrome) and irreversible neurologic dysfunction are also contraindications for intestinal transplantation; these comorbid conditions substantially limit post‑transplant survival and may preclude candidacy.

Pre-Transplant Evaluation and Documentation Requirements

Documentation Required

EVALUATION REQUIREMENTS: clinical notes and specialty consults

Provide the last 6 months of clinical notes from the requesting provider and/or specialist; include evidence of oncology consultation for prior malignancy and documentation of social support and adherence history as part of the evaluation package.

Last 6 months of clinical notes from requesting provider/specialist.
Oncology consultation when there is a history of malignancy to assess recurrence risk.
Documentation of social support and a record of adherence to medical treatment.

Transplant Center and Caregiver Requirements

Note

Center requirements: travel and caregiver availability

Ensure the patient and caregiver(s) are willing and able to travel on short notice to a Kaiser Permanente–approved transplant Center of Excellence and to return for treatment of complications; caregiver(s) must be physically and cognitively able to assist with self‑care and travel on short notice.

Definitions and Background

Multivisceral transplantation (MVT) — definition and key points

DefinitionEn-bloc transplantation of three or more abdominal organs that include liver, stomach, pancreatic-duodenal complex and intestine with or without right hemi-colon.

Also calledMultivisceral transplantation (MVT).

Typical indicationsOffered to patients with locally aggressive tumors requiring massive evisceration of abdominal organs.

Notes on regulationThe FDA does not regulate the surgical procedure of MVT; immunosuppressive drugs used are FDA-regulated.

Indications for isolated intestinal graft

IndicationsPatients with fluid and electrolyte loss not manageable by TPN, severely limited venous access, and/or moderate liver dysfunction secondary to TPN.

Isolated intestinal graft appropriate whenTPN cannot manage fluid/electrolyte losses or venous access is severely limited.

Combined SB/LT indicationReserved for irreversible liver failure due to TPN or intestinal/liver failure where simultaneous liver graft corrects a hypercoagulable state.

Clinical roleIntestinal transplantation is not an alternative to TPN and is intended for patients predicted to have poor survival on long-term TPN.

Intestinal transplantation is a complex, evolving therapy for irreversible intestinal failure and may be performed as an isolated small bowel transplant (SBT), combined small bowel/liver transplant (SB/LT), or multivisceral transplant (MVT). MVT is defined as en‑bloc transplantation of three or more abdominal organs (for example, liver, stomach, pancreatic‑duodenal complex, and intestine, with or without the right hemi‑colon). Historically the procedure carried high morbidity and mortality, but outcomes have improved with advances in surgical technique and immunosuppression; nevertheless, patient survival remains the primary outcome of interest. Tacrolimus is the primary immunosuppressant commonly used in these transplants and is FDA‑approved for rejection prophylaxis in allogenic liver transplantation.

Post-Transplant Care and Coverage

Immunosuppressive therapy and infection prophylaxis

Policy statementPost-transplant immunosuppression and infection prophylaxis are standard parts of care; specifics are not detailed in this document.

Common immunosuppressantTacrolimus is the primary immunosuppressant used and was FDA-approved for allogenic liver transplantation in 1994; it is commonly used in intestinal transplants.

RationaleImproved surgical techniques and more potent immunosuppressive drugs have reduced morbidity and mortality associated with intestinal transplantation.

Clinical considerationsIntestines are more susceptible to rejection and carry higher risk of graft-versus-host disease; infection prophylaxis and lymphoproliferative disease prophylaxis are standard practice.

OpenPayer