CurrentPremera Blue Cross of WashingtonPolicy 7.03.511

Small Bowel Transplantation

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This policy addresses when isolated small bowel, living-donor small bowel, and small bowel retransplantation may be considered medically necessary for adult and pediatric individuals, including documentation, coding, contraindications, and facility requirements.

Policy Summary

PayerPremera Blue Cross of Washington

PolicySmall Bowel Transplantation

Policy CodePolicy 7.03.511

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionBefore transplantation, establish TPN failure and confirm that the procedure will be performed at an approved transplant facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Transplant pathways addressed

4Specified TPN failure manifestations

10/yearMinimum facility volume

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CurrentPremera Blue Cross of WashingtonPolicy 7.03.511

Small Bowel Transplantation

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Sign up for premerabluecrossofwashington Policy 7.03.511 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicySmall Bowel Transplantation

Policy CodePolicy 7.03.511

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionBefore transplantation, establish TPN failure and confirm that the procedure will be performed at an approved transplant facility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Transplant pathways addressed

4Specified TPN failure manifestations

10/yearMinimum facility volume

65%Required one-year facility survival

Small Bowel Transplant Coverage Criteria

Cadaveric small bowel transplant

May be considered medically necessary when ALL of the following are met.

Cadaveric small bowel transplant: Adult or pediatric individual with intestinal failure characterized by loss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance; established long-term dependence on total parenteral nutrition (TPN); and developing or having developed severe complications due to TPN.

The transplant uses cadaveric intestine.

Living-donor small bowel transplant

May be considered medically necessary only when ALL of the following are met.

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

Living-donor transplantation is not medically necessary in other situations.

Small bowel retransplant

May be considered medically necessary when the following condition is met.

Small bowel retransplant: The individual has experienced a failed primary small bowel transplant.

Retransplantation remains subject to continued transplant candidacy and absence of contraindications.

Investigational

Considered investigational when the following condition is present.

Investigational small bowel transplant: Adult or pediatric individual with intestinal failure who can tolerate total parenteral nutrition (TPN).

Small bowel transplantation is considered investigational in this circumstance.

Intestinal and multivisceral transplantation

Intestinal and multivisceral transplantation is covered only when all of the following are met.

Required coverage conditions

TPN failure
- TPN-induced liver failure: Impending or overt liver failure due to TPN-induced liver injury.
- Central venous thrombosis: Thrombosis of the major central venous channels, including the jugular, subclavian, or femoral veins.
- Line infection or sepsis: Frequent line infection and sepsis.
- Severe dehydration:

A living-donor small bowel transplant is considered not medically necessary in all situations other than when a cadaveric intestine is unavailable and the individual meets the criteria for cadaveric intestinal transplantation.

A living-donor small bowel transplant is not medically necessary when the individual does not meet the criteria for cadaveric intestinal transplantation or when a cadaveric intestine is available.

Billing and Coding

CPT CodesCPT

44135	Intestinal allotransplantation; from cadaver donor.
44136

HCPCS CodesHCPCS

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 with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre and posttransplant care in the global definition

TPN-Related Liver Disease

ThresholdTotal bilirubin greater than 3 mg/dL

Clinical significanceOften associated with irreversible, progressive liver disease

Relevant settingLiver disease with jaundice in individuals receiving total parenteral nutrition

Authorization and Provider Responsibilities

Prior Authorization

Prior Authorization: TPN Failure and Approved Facility

Authorization for intestinal or multivisceral transplantation requires documentation that the individual has failed total parenteral nutrition (TPN) and that the transplant will be performed at an approved transplant facility.

TPN failure may include TPN-induced liver failure, thrombosis of major central venous channels, frequent line infections or sepsis, or recurrent severe dehydration despite supplemental intravenous fluids.
Approved centers generally perform at least 10 intestinal transplants annually and have a one-year actuarial survival rate of at least 65% using the Kaplan-Meier technique.

Documentation Required

Required Clinical Documentation

Submit medical records demonstrating that the medical-necessity criteria are met. Office visit notes should include the relevant history and physical findings supporting intestinal failure, long-term TPN dependence, and severe TPN-related complications.

Clinical Background

Intestinal failure is characterized by inadequate absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance. It may result in long-term dependence on total parenteral nutrition (TPN); transplantation may be considered when severe TPN-related complications develop.

Key Definitions

Intestinal Failure

Core featureLoss of absorption

Nutritional balanceInability to maintain protein-energy balance

Physiologic balanceInability to maintain fluid, electrolyte, or micronutrient balance

Qualifying TPN Dependence

Nutrition requirementEstablished long-term dependence on total parenteral nutrition (TPN)

Complication requirementDevelopment of severe complications attributable to TPN

Policy relevanceSupports consideration of small bowel transplantation when the qualifying criteria are met

Transplant Candidate Requirements

Small bowel transplant candidate criteria

Small bowel transplant may be considered medically necessary when ALL of the following apply.

Small bowel transplant candidate

Intestinal failure: Loss of absorption and inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.
Applies to adult and pediatric individuals.
Long-term TPN dependence: Established long-term dependence on total parenteral nutrition.
Severe TPN complications: Developing or having developed severe complications due to total parenteral nutrition.
Examples include recurrent catheter-related sepsis, progressive liver failure, and inability to maintain venous access.

Transplant Contraindications

Current malignancy, including metastatic cancer, is a potential contraindication to solid organ transplantation and may affect transplant candidacy.

A recent malignancy with a high risk of recurrence is a potential contraindication to solid organ transplantation and may affect transplant candidacy.

An untreated systemic infection, including chronic infection, is a potential contraindication when immunosuppression would be unsafe.

An irreversible end-stage disease not attributed to intestinal failure is a potential contraindication to transplantation.

A history of cancer with a moderate risk of recurrence is a potential contraindication to transplantation.

A systemic disease that could be exacerbated by immunosuppression is a potential contraindication to transplantation.

Psychosocial conditions or chemical dependency that affect the individual's ability to adhere to therapy are potential contraindications to transplantation.

Clinical Evaluation and Documentation

Documentation Required

Document the transplant evaluation

Submit office visit notes with relevant history and physical findings documenting intestinal failure, long-term TPN dependence, and severe TPN-related complications. Identify whether the request is for cadaveric transplantation, living-donor transplantation, or retransplantation.

Documentation Required

Document qualifying TPN failure

Before transplantation, document failure of TPN and the qualifying complication or complications. Qualifying manifestations include TPN-induced liver failure, major central venous thrombosis, frequent line infection and sepsis, or frequent severe dehydration despite intravenous fluid supplementation in addition to TPN.

Documentation Required

Confirm transplant facility eligibility

Before transplantation, document failure of TPN and the qualifying complication or complications, and confirm that the transplant facility meets the specified volume and one-year survival criteria.

Approved Transplant Facility Standards

Prior Authorization

Verify center requirements

Use an approved transplant facility meeting both center standards: a volume of at least 10 intestinal transplants per year and one-year actuarial survival of 65% using the Kaplan-Meier technique.

Approved transplant facility
At least 10 intestinal transplants per year
One-year actuarial survival of 65% using the Kaplan-Meier technique

Policy Summary

PayerPremera Blue Cross of Washington

PolicySmall Bowel Transplantation

Policy CodePolicy 7.03.511

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionBefore transplantation, establish TPN failure and confirm that the procedure will be performed at an approved transplant facility.

SourceLink

On This Page

Frequent episodes of severe dehydration despite intravenous fluid supplementation in addition to TPN.

Approved transplant facility: The transplant is performed at a facility meeting the approval criteria.10 intestinal transplants per year and one-year actuarial survival of 65% using the Kaplan-Meier technique

Specify whether the request is for a cadaveric transplant, living-donor transplant, or retransplantation.

Documentation Required

Document TPN Failure and Facility Qualification

The submitted documentation must establish both the qualifying TPN failure and the transplant facility's approval or qualification status.

Document the applicable TPN-failure complication(s).
Identify the transplant center and provide information supporting its qualification under applicable approval criteria.

Denial Risk

TPN Tolerance Is Investigational

Small bowel transplantation is considered investigational for adults and children with intestinal failure who can tolerate total parenteral nutrition.

Requests for individuals who remain able to tolerate TPN do not meet the policy's medical-necessity criteria.

Denial Risk

Living Donor Requires a Qualifying Indication

A living-donor small bowel transplant may be medically necessary only when a cadaveric intestine is unavailable and the individual meets the qualifying criteria for cadaveric transplantation. Living-donor transplantation is not medically necessary in all other situations.

The qualifying indication includes intestinal failure, established long-term TPN dependence, and severe complications caused by TPN.

Denial Risk

Review Transplant Contraindications

Transplant candidacy is subject to the judgment of the transplant center and may be limited by contraindications that make transplantation or immunosuppression unsafe.

Known current malignancy, including metastatic cancer, or recent malignancy with high recurrence risk.
Untreated systemic infection, including chronic infection, that makes immunosuppression unsafe.
Other irreversible end-stage disease not attributable to intestinal failure.
History of cancer with moderate recurrence risk.
Systemic disease that could be exacerbated by immunosuppression.
Psychosocial conditions or chemical dependency affecting adherence to therapy.

Denial Risk

Failure to Meet TPN or Facility Requirements

Coverage may be denied when the request does not demonstrate TPN failure or when the transplant is not performed at a facility meeting applicable approval criteria.

TPN failure includes impending or overt TPN-induced liver failure, thrombosis of major central venous channels, frequent line infection or sepsis, and frequent severe dehydration despite intravenous fluid supplementation in addition to TPN.
Confirm both the clinical failure of TPN and the qualifying status of the transplant facility before submitting the request.

Short Bowel Syndrome

Surgical causeSurgical resection can result in short bowel syndrome

Congenital causeA congenital defect can result in short bowel syndrome

Disease-associated causeDisease-associated loss of absorption can result in short bowel syndrome

Relationship to intestinal failureShort bowel syndrome is one cause of intestinal failure

Total Parenteral Nutrition (TPN)

Route of deliveryNutrients are delivered intravenously

Absorption bypassedTPN avoids the need for absorption through the small bowel

Clinical roleProvides nutritional support when small-bowel absorption is inadequate

TPN Failure

Liver failureImpending or overt liver failure due to TPN-induced liver injury

Central venous thrombosisThrombosis of the major central venous channels, including the jugular, subclavian, and femoral veins

Line infection and sepsisFrequent line infection and sepsis

Severe dehydrationFrequent episodes of severe dehydration despite intravenous fluid supplementation in addition to TPN

Intestinal transplantation candidate criteria

Candidates must have failed TPN and be treated at an approved transplant facility.

Intestinal transplantation candidate

TPN failure manifestation: At least one of the following is present: impending or overt TPN-induced liver failure; thrombosis of major central venous channels, including the jugular, subclavian, or femoral veins; frequent line infection and sepsis; or frequent episodes of severe dehydration despite intravenous fluid supplementation in addition to TPN.
Facility approval criteria: The facility performs at least 10 intestinal transplants per year and achieves one-year actuarial survival of 65% using the Kaplan-Meier technique.10 intestinal transplants per year; 65% one-year actuarial survival

At least 10 intestinal transplants per year
One-year actuarial survival of 65% using the Kaplan-Meier technique