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    OpenPayerPolicy UpdatesTransplantPHC California Transplant Coverage | OpenPayer
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    ModifiedPositive Healthcare (PHC) CaliforniaPolicy CG-UM-009

    Small Bowel, Small Bowel/Liver and Multivisceral Transplantation

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    This policy governs medical necessity for isolated small bowel, combined small bowel/liver, multivisceral, living-donor, deceased-donor, and retransplantation procedures in adults and children. Coverage depends primarily on irreversible intestinal failure or short bowel syndrome, failure of total parenteral nutrition, transplant selection criteria, and absence of contraindications.

    Policy Summary
    PayerPositive Healthcare (PHC) California
    PolicySmall Bowel, Small Bowel/Liver and Multivisceral Transplantation
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument short bowel syndrome or irreversible intestinal failure, the applicable TPN-failure pathway, the proposed transplant type and donor source, selection criteria, and absence of contraindications.
    SourceLink
    POLICY UPDATE CHANGES

    The November 10, 2022 revision added the term "multivisceral" and language including treatment of pseudomyxoma peritonei to the first investigational and not medically necessary statement.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3Transplant types addressed
    4TPN failure pathways
    2+Central venous thromboses qualifying as TPN failure
    2/yearHospitalized line-sepsis episodes qualifying as TPN failure
    >200Required HIV/AIDS exception CD4 count

    Covered and Non-Covered Transplant Services

    Cadaveric Small Bowel Transplant

    Covered when all of the following are met:

    Cadaveric small bowel transplant

    • One qualifying TPN-failure pathway

      • TPN-induced liver failure: Impending or overt liver failure due to TPN-induced liver injury.

        Clinical indicators may include increased serum bilirubin or liver enzyme levels, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding, hepatic fibrosis, or cirrhosis.

      • Central venous thrombosis: Thrombosis of two or more major central venous channels.2 or more channels

        Channels include the subclavian, jugular, or femoral veins.

      • Central line-related sepsis: Frequent central line-related sepsis.2 or more hospitalized episodes of line-induced systemic sepsis per year; or 1 episode of line-related fungemia, septic shock, or acute respiratory distress syndrome
      • Severe dehydration: Frequent episodes of severe dehydration despite TPN and intravenous fluid supplementation.

        This may occur when gastrointestinal and pancreatobiliary secretions exceed the maximum intravenous infusion rates tolerated by the cardiopulmonary system.

    • General selection criteria: The individual has no applicable contraindication under the general individual selection criteria.

    Living-Donor Small Bowel Transplant

    Covered when all of the following are met:

    Living-donor small bowel transplant: The individual meets the criteria for cadaveric intestinal transplantation and a cadaveric intestine is not available for transplantation.

    Combined Small Bowel/Liver Transplant

    Covered when all of the following are met:

    Combined small bowel/liver transplant: The adult or child meets criteria for intestinal transplantation and has overt or imminent liver failure or anatomical abnormalities that preclude an isolated small bowel transplant, and a cadaveric intestine is not available for transplantation.

    The policy specifies combined transplantation from deceased donors.

    Multivisceral Transplant

    Covered when all of the following are met:

    Multivisceral transplant: The adult or child meets the criteria for combined small bowel/liver transplantation and requires one or more additional abdominal visceral organs to be transplanted because of concomitant organ failure or anatomical abnormalities that preclude a small bowel/liver transplant.

    The policy specifies multivisceral transplantation from deceased donors.

    Small bowel transplantation is not medically necessary for adults or children who can tolerate total parenteral nutrition (TPN).

    Living-donor small bowel transplantation is not medically necessary for adults or children when a cadaveric intestine is available for transplantation.

    Living-donor multivisceral transplantation in adults or children is considered investigational and not medically necessary.

    All other indications for small bowel or multivisceral transplantation in adults or children are considered investigational and not medically necessary, including, but not limited to, treatment of pseudotumor peritonei.

    Transplantation is not medically appropriate when an absolute contraindication is present, including metastatic cancer; ongoing or recurring infections that are not effectively treated; serious cardiac or other insufficiencies that prevent the individual from tolerating transplant surgery; serious conditions unlikely to improve with transplantation when life expectancy can be finitely measured; demonstrated noncompliance that places the organ at risk; or unacceptable potential complications from immunosuppressive medications. AIDS is also an absolute contraindication unless all stated exceptions are met: CD4 count greater than 200 cells/mm3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications, and fulfillment of all other small bowel or multivisceral transplant criteria.

    For the listed procedure codes, services are not medically necessary when the applicable criteria are not met or when the code describes a procedure identified in the Position Statement as not medically necessary.

    For the listed procedure codes, services are investigational and not medically necessary for all other indications, including secondary malignant neoplasm of the retroperitoneum and peritoneum specified as pseudomyxoma peritonei (ICD-10-CM C78.6), or when the code describes a procedure identified in the Position Statement as investigational and not medically necessary.

    Procedure, Diagnosis, and Qualifying Clinical Codes

    Procedures applicable when medically necessary criteria are metCPT
    44132Donor enterectomy (including cold preservation), open; from cadaver donor
    44133Donor enterectomy (including cold preservation), open; partial, from living donor
    44135Intestinal allotransplantation; from cadaver donor
    44136Intestinal allotransplantation; from living donor
    44715Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
    44720Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
    44721Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
    47143Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
    47144Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into two partial liver grafts (i.e., left lateral segment (segments II and III) and right trisegment (segments I and IV through VIII)
    47145Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (i.e., left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII)
    1–10 of 11
    1/2
    CPT codesCPT
    44132Donor enterectomy (including cold preservation), open; from cadaver donor
    44133Donor enterectomy (including cold preservation), open; partial, from living donor
    44135Intestinal allotransplantation; from cadaver donor
    44136Intestinal allotransplantation; from living donor
    44715Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
    44720Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
    44721Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
    47143Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
    47144Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into two partial liver grafts (i.e., left lateral segment (segments II and III) and right trisegment (segments I and IV through VIII)
    47145Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into two partial liver grafts (i.e., left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII)
    1–10 of 14
    1/2
    HCPCS codesHCPCS
    S2053Transplantation of small intestine and liver allografts
    S2054Transplantation of multivisceral organs
    S2055Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor
    ICD-10 Procedure codesICD-10
    0DT80ZZResection of small intestine, open approach
    0FT00ZZResection of liver, open approach
    0FTG0ZZResection of pancreas, open approach
    0DY60Z0Transplantation of stomach, allogeneic, open approach
    0DY60Z1Transplantation of stomach, syngeneic, open approach
    0DY80Z0Transplantation of small intestine, allogeneic, open approach
    0DY80Z1Transplantation of small intestine, syngeneic, open approach
    0DYE0Z0Transplantation of large intestine, allogeneic, open approach
    0DYE0Z1Transplantation of large intestine, syngeneic, open approach
    0FY00Z0Transplantation of liver, allogeneic, open approach
    1–10 of 13
    1/2
    ICD-10 DiagnosisICD-10
    All diagnosesAll diagnoses
    Investigational and Not Medically Necessary DiagnosisICD-10Experimental
    C78.6Secondary malignant neoplasm of retroperitoneum and peritoneum [specified as pseudomyxoma peritonei]
    Central venous thrombosis
    Qualifying conditionThrombosis of two or more major central venous channels is considered TPN failure.
    qualifying thresholdTwo or more vessels.
    Included vesselsSubclavian, jugular, or femoral veins.
    Line-related sepsis
    Hospitalized sepsis thresholdTwo or more episodes of line-induced systemic sepsis per year that require hospitalization qualify as TPN failure.
    Single qualifying episode

    Documentation and Denial-Risk Conditions

    Documentation Required

    Document Transplant Medical Necessity

    Document the qualifying short bowel syndrome or irreversible intestinal failure, the failed-TPN pathway, the proposed transplant, and the applicable individual-selection criteria. Cadaveric small bowel transplantation requires documented TPN failure and no American Society of Transplantation contraindication; living-donor transplantation must meet the same criteria, and combined small bowel/liver transplantation additionally requires overt or imminent liver failure or an anatomical abnormality precluding isolated transplantation when a cadaveric intestine is unavailable.

    • Document TPN failure through at least one qualifying pathway: TPN-induced impending or overt liver failure; thrombosis of at least two major central venous channels; frequent central-line sepsis; or frequent severe dehydration despite TPN and intravenous fluids.
    • For line-related sepsis, document at least two hospitalization-requiring episodes in a year, or one episode of line-related fungemia, septic shock, or acute respiratory distress syndrome.
    • For severe dehydration, document that gastrointestinal and pancreatobiliary fluid losses exceed the maximum intravenous infusion rates tolerated by the cardiopulmonary system, when applicable.
    • Document the proposed transplant type and that the individual does not have an applicable absolute contraindication.

    Clinical Context

    Intestinal failure and short bowel syndrome impair the absorption of nutrition, fluids, and electrolytes. Short bowel syndrome is a malabsorption condition resulting from a significantly reduced small intestine, and affected individuals may require long-term total parenteral nutrition (TPN) to meet nutritional and fluid needs. TPN may cause serious complications, including liver injury, central venous thrombosis, catheter-related sepsis, and severe dehydration.

    Policy Terms

    Definitions
    TermCadaver.
    DefinitionThe physical remains of a deceased person.
    Policy usageThe term identifies an organ or donor source involving a deceased person.
    Definitions
    TermShort bowel syndrome.
    DefinitionA malabsorption syndrome resulting from a significantly reduced small intestine.
    Clinical effectThe syndrome results from a significantly reduced small intestine.

    Transplant Candidate Selection

    General Individual Selection Criteria

    The candidate must meet the applicable transplant indication and have no contraindication:

    General transplant candidacy: Meet the applicable clinical indication for small bowel, small bowel/liver, or multivisceral transplantation; meet the relevant TPN-failure or organ-failure criteria; and have no absolute contraindication listed by the policy.

    Absolute Transplant Contraindications

    Absolute contraindications to transplantation include: metastatic cancer; ongoing or recurring infections that are not effectively treated; serious cardiac or other ongoing insufficiencies creating an inability to tolerate transplant surgery; serious conditions unlikely to be improved by transplantation because life expectancy can be finitely measured; demonstrated patient noncompliance that places the organ at risk through failure to follow medical recommendations; and potential complications from immunosuppressive medications that are unacceptable to the patient. AIDS, based on the CDC definition of a CD4 count of 200 cells/mm3, is also an absolute contraindication unless the individual has a CD4 count greater than 200 cells/mm3 for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no other AIDS complications, and meets all other transplant criteria.

    Required Clinical Evaluation

    Documentation Required

    Complete the transplant evaluation

    Before submitting the transplant request, establish short bowel syndrome or irreversible intestinal failure and the applicable transplant indication; assess whether TPN has failed using a qualifying clinical pathway; determine whether liver failure, concomitant abdominal organ failure, or anatomical abnormalities require isolated small bowel, combined small bowel/liver, or multivisceral transplantation; and screen for absolute contraindications.

    • Document compliance with the applicable general individual selection criteria.
    • Evaluate the proposed transplant type and donor source against the policy requirements.
    Policy Summary
    PayerPositive Healthcare (PHC) California
    PolicySmall Bowel, Small Bowel/Liver and Multivisceral Transplantation
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument short bowel syndrome or irreversible intestinal failure, the applicable TPN-failure pathway, the proposed transplant type and donor source, selection criteria, and absence of contraindications.
    SourceLink
    On This Page
    Covered and Non-Covered Transplant ServicesProcedure, Diagnosis, and Qualifying Clinical CodesDocumentation and Denial-Risk ConditionsClinical ContextPolicy TermsTransplant Candidate SelectionAbsolute Transplant ContraindicationsRequired Clinical Evaluation
    One episode of line-related fungemia, septic shock, or acute respiratory distress syndrome qualifies as TPN failure.
    Clinical contextThe episodes must be related to a central line.
    HIV/AIDS CD4 count
    Required CD4 countGreater than 200 cells/mm3.
    Required durationThe CD4 count must remain greater than 200 cells/mm3 for greater than 6 months.
    Eligibility contextThis is an exception requirement for individuals with AIDS, together with the policy’s other transplant criteria.
    Stable antiretroviral therapy
    Therapy requirementThe individual must be on stable antiretroviral therapy.
    Required durationStable antiretroviral therapy must be maintained for greater than 3 months.
    Eligibility contextThis is part of the stated exception criteria for individuals with AIDS.
    Documentation Required

    Document HIV/AIDS Eligibility

    For an individual with AIDS, document the exception requirements before proceeding with transplant consideration. AIDS is an absolute contraindication unless all stated HIV-related and transplant-selection requirements are satisfied.

    • CD4 count greater than 200 cells/mm³ for more than 6 months.
    • HIV-1 RNA undetectable.
    • Stable antiretroviral therapy for more than 3 months.
    • No other AIDS complications, including opportunistic infection, aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infection, Kaposi's sarcoma, or other neoplasm.
    • All other criteria for small bowel or multivisceral transplantation are met.
    Denial Risk

    TPN Tolerated: Denial Risk

    A small bowel transplant is considered not medically necessary when the individual can tolerate total parenteral nutrition.

    • Document the clinical basis for TPN intolerance or failure when requesting transplant coverage.
    Denial Risk

    Cadaveric Intestine Available: Denial Risk

    A living-donor small bowel transplant is considered not medically necessary when a cadaveric intestine is available for transplantation.

    • Verify and document whether a suitable cadaveric intestine is available before requesting coverage for living-donor transplantation.
    Denial Risk

    Unlisted or Investigational Indication

    All other indications for small bowel or multivisceral transplantation are investigational and not medically necessary, including treatment of pseudotumor peritonei. Living-donor multivisceral transplantation is also investigational and not medically necessary.

    • Do not submit an unlisted indication as medically necessary without documentation that it falls within the covered criteria.
    • Pseudotumor peritonei, including pseudomyxoma peritonei, is specifically identified as an investigational indication.
    Denial Risk

    Absolute Contraindication: Denial Risk

    Flag denial risk when an absolute contraindication to transplantation is present. The policy incorporates the American Society of Transplantation contraindications, including the following conditions.

    • Metastatic cancer.
    • Ongoing or recurring infections that are not effectively treated.
    • Serious cardiac or other ongoing insufficiency that prevents tolerance of transplant surgery.
    • Serious conditions unlikely to improve with transplantation when life expectancy can be finitely measured.
    • Demonstrated noncompliance that places the organ at risk by failure to follow medical recommendations.
    • Unacceptable potential complications from immunosuppressive medications.
    • AIDS, unless all stated CD4, HIV-1 RNA, antiretroviral-therapy, complication, and other-transplant-criteria exceptions are met.
    Denial Risk

    Criteria Not Met: Denial Risk

    For the applicable procedure codes, services are not medically necessary when the policy criteria are not met or when the code describes a procedure identified in the Position Statement as not medically necessary.

    • Confirm that the documented indication, TPN-failure pathway, transplant type, and individual-selection criteria satisfy the policy before submission.
    Denial Risk

    Investigational Indication: Denial Risk

    For the applicable procedure codes, services are investigational and not medically necessary for other indications, including diagnoses or procedures identified by the policy as investigational and not medically necessary.

    • Flag ICD-10-CM C78.6, secondary malignant neoplasm of retroperitoneum and peritoneum specified as pseudomyxoma peritonei, as an investigational and not medically necessary indication.
    Definitions
    TermTotal parenteral nutrition (TPN).
    DefinitionA method of supplying nourishment to children and adults who are unable to eat.
    Use in policyTPN is the nutrition-supply method referenced when evaluating intestinal failure and TPN failure.