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A small bowel transplant is typically performed in patients with short bowel syndrome. This is a condition in which the absorbing surface of the small intestine is inadequate due to extensive disease or surgical removal of a large portion of small intestine. In adults, etiologies of short bowel syndrome include ischemia, trauma, volvulus, and tumors. In children, gastroschisis, volvulus, necrotizing enterocolitis, and congenital atresias are predominant causes.
The small intestine, particularly the ileum, does have the capacity to adapt to some functions of the diseased or removed portion over a period of 1 to 2 years. Prognosis for recovery depends on the degree and location of small intestine damage. Therapy is focused on achieving adequate macro- and micronutrient uptake in the remaining small bowel. Pharmacologic agents have been studied to increase villous proliferation and slow transit times, and surgical techniques have been advocated to optimize remaining small bowel. However, some patients with short bowel syndrome are unable to obtain adequate nutrition from enteral feeding and become chronically dependent on total parenteral nutrition (TPN). Patients with complications from TPN may be considered candidates for small bowel transplant. Complications include catheter-related mechanical problems, infections, hepatobiliary disease, and metabolic bone disease. While cadaveric intestinal transplant is the most commonly performed transplant, there has been recent interest in using living donors.
Intestinal transplants (including multivisceral and bowel/liver) represent a small minority of all solid organ transplants. In 2011, 129 intestinal transplants were performed in the United States, of which all but one was from deceased donors. In 2012, 106 intestinal transplants were performed in the United States; all were from deceased donors.
A small bowel transplant may be performed as an isolated procedure or in conjunction with other visceral organs, including the liver, duodenum, jejunum, ileum, pancreas, or colon. When the small bowel and liver are transplanted in conjunction with other gastrointestinal organs, the procedure is referred to as a multivisceral transplant. Small Bowel/Liver Transplants and Multivisceral Transplants are addressed in a separate policy.
POLICYNo benefits will be provided for a covered transplant procedure unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
Small Bowel Transplant coverage is as follows:
HIV positivity is not an absolute contraindication to transplant. Each individual transplant center will determine patient selection criteria for HIV positive patients.
The Following may be used as a Guideline for Patient Selection Criteria:
Coverage is not provided for:
Small Bowel Specific
Intestinal failure results from surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance. Short-bowel syndrome is one case of intestinal failure.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
1/17/2001: Code reference section updated
5/2001: Reviewed by MPAC; changed to investigational status
7/16/2001: Policy exception for FEP added
8/2001: Reviewed by MPAC; medically necessary indication added.
2/13/2002: Investigational definition added, Prior written approval added
3/6/2002: Prior authorization through case management added
5/7/2002: Type of Service and Place of Service deleted
5/28/2002: Code Reference section updated, CPT code range 44132-44136 listed separately
7/21/2005: Policy updated: "HIV positivity is not an absolute contraindication to transplant. Each individual transplant center will determine patient selection criteria for HIV positive patients." added
10/19/2005: Code Reference table updated: Non-Covered table added, CPT codes 44137, 44715, 44720, 44721 added to covered table, 44133, 44136 added to non-covered table, 44120, 44121, "with preparation and maintenance of allograft;" deleted; ICD-9 procedure codes 00.91, 00.92 added to non-covered table, 00.93 added to covered table.
12/31/2008: Policy reviewed, prior authorization of evaluation removed
4/22/09: Policy reviewed, no changes
12/07/2009: Policy Description Section revised as follows: Additional information on small bowel syndrome, living donors, and complications of small bowel transplants added. Link added to related policy, Small Bowel/Liver Transplants and Multivisceral Transplants. Policy Statement Section revised as follows: Evidence of impending end-stage liver failure removed from the medically necessary criteria for cadaveric small bowel transplants. Intestinal failure and developing or already developed severe complications due to TPN added to medically necessary criteria for cadaveric small bowel transplants. Added verbiage "with intestinal failure" to investigational criteria. Small bowel transplants from living donors changed from investigational to may be considered medically necessary only when cadaveric transplants are not available, but all other situations for small bowel transplants from living donors is considered not medically necessary. Guideline added for patient selection criteria. Non-coverage information added. Coding Section revised as follows: CPT4 codes 44133, 44136, and ICD9 procedure codes 00.91, 00.92 moved from Non-Covered Codes Table to Covered Codes Table. CPT4 code 44175 corrected to 44715. CPT4 code 44137 removed from Covered Codes Table. ICD9 procedure codes 46.62 and 45.63 added to Covered Codes Table. Non-Covered Codes Table removed. Verbiage added "*Some covered procedure codes may have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section."
12/01/2011: Policy reviewed; no changes.
12/12/2012: Policy reviewed; no changes.
01/22/2014: Added the following policy statement: A small bowel retransplant may be considered medically necessary after a failed primary small bowel transplant.
10/30/2014: Added "Isolated" to the policy title. Pediatric patients added to the investigational policy statement on patients with intestinal failure who are able to tolerate TPN.
08/28/2015: Code Reference section updated for ICD-10. Removed outdated references from the Sources section.
02/15/2016: Policy description updated to add information regarding the small intestine and prognosis for recovery. Policy statements unchanged. Policy guidelines updated regarding intestinal failure and to add medically necessary and investigational definitions.
06/01/2016: Policy number added.
Blue Cross Blue Shield Association policy ## 7.03.05
Blue Cross Blue Shield Association policy # 7.03.04
CODE REFERENCEThis may not be a comprehensive list of precedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.