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A small bowel transplant may be performed 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.

Small Bowel Transplant coverage is as follows:

1. Small Bowel Transplant using a cadaveric intestine may be considered medically necessary in adult and pediatric patients with intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance), who have established long-term dependency on total parenteral nutrition (TPN) and are developing or have developed severe complications due to TPN.
2. A Small Bowel Transplant is considered investigational for adults with intestinal failure who are able to tolerate TPN.
3. Small Bowel Transplant using living donors may be considered medically necessary only when a cadaveric intestine is not available for transplantation in a patient who meets the criteria noted above for a cadaveric intestinal transplant.
4. Small bowel transplant using living donors is considered not medically necessary in all other situations.

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:

• Services for which the cost is covered/funded by governmental, foundation, or charitable grants
• Organs sold rather than donated to the recipient
• An artificial organ

None

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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.

TEC Assessments 1995

Small Bowel/Liver Transplant: Surgery Section # 7.03.05

Blue Cross Blue Shield Association policy # 7.03.04

Hayes Medical Technology Directory

HCFA, Transmittal AB-01-58, April 12, 2001

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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