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DESCRIPTIONSmall bowel/liver transplantation is transplantation of an intestinal allograft in combination with a liver allograft, either alone or in combination with one or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.
Small bowel transplants are typically performed in patients with short bowel syndrome, defined as an inadequate absorbing surface of the small intestine due to extensive disease or surgical removal of a large portion of small intestine. In some instances, short bowel syndrome is associated with liver failure, often due to the long-term complications of total parenteral nutrition (TPN). These patients may be candidates for a small bowel/liver transplant or a multivisceral transplant, which includes the small bowel and liver with 1 or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, and/or colon. A multivisceral transplant is indicated when anatomic or other medical problems preclude a small bowel/liver transplant.
Isolated Small Bowel Transplants are addressed in a separate policy.
POLICYNo benefits will be provided for a covered transplant procedure or a transplant evaluation unless the Member receives prior authorization through case management from Blue Cross & Blue Shield of Mississippi.
A small bowel/liver transplant or multivisceral transplant may be considered medically necessary for pediatric and adult patients with intestinal failure (characterized by loss of absorption and the inablility to maintain protein-energy, fluid, electrolyte, or micronutrient balance), who have been managed with long-term total parental nutrition (TPN) and who have developed evidence of impending end-stage liver failure.
A small bowel/liver retransplant or multivisceral retransplant may be considered medically necessary after a failed primary small bowel/liver transplant or multivisceral transplant.
A small bowel/liver transplant or multivisceral transplant is not medically necessary in patients with the following absolute contraindications:
Coverage is not provided for:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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.
Candidates should meet the following criteria:
HIV-positive patients who meet the following criteria, as stated in the 2001 guidelines of the American Society of Transplantation, could be considered candidates for small bowel/live or multivisceral transplantation:
Small Bowel/Liver Specific
Evidence of intolerance of total parenteral nutrition (TPN) includes, but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications, or the development of progressive but reversible liver failure. In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.
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.
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/2001: Reviewed by MPAC
2/15/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
7/21/2005: Reviewed by MPAC; "HIV positivity is not an absolute contraindication to transplant. Each individual transplant center will determine patient selection criteria for HIV positive patients."
10/19/2005: Code Reference table updated: Non-Covered Codes table added; CPT codes 44132, 44135, 44137, 44715, 44720, 44721, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147 added to covered table, 44133, 44136 added to non-covered table, 44120, 44121, 44799, 47134 deleted; ICD-9 procedure codes 00.91, 00.92, 00.93, 46.97, 50.22, 50.4, 50.51 added, 50.5 deleted; HCPCS codes S2053, S2152 added to covered table, S2054, S2055 added to non-covered table; diagnosis codes 996.82, 886.89, V42.07, V42.8 deleted.
3/24/2006: Coding updated. CPT4 2006 revisions added to policy
11/10/2006: Multivisceral transplant changed from "investigational" to "medically necessary". Policy name changed from Small Bowel, Liver and Mutivisceral Transplant to Multivisceral Transplant. Code reference table updated: HCPCS code S2054 and S2055 added to covered codes.
12/07/2009: Policy Title revised to add "Small Bowel/Liver and". Policy Description Section revised with link to related policy, Small Bowel Transplants. Policy Statement Section revised as follows: Replaced medically necessary verbiage "short bowel syndrome" with "intestinal failure (characterized by loss of absorption and the inablility to maintain protein-energy, fluid, electrolyte, or micronutrient balance)". Patient Selection Criteria Guideline added. Non-coverage information added. Coding Section revised as follows: CPT4 codes 44133 and 44136 moved from Non-Covered Codes Table to Covered Codes Table, ICD9 procedure code 45.62 added to Covered Codes Table, ICD9 diagnosis code 570 added to Covered Codes Table. CPT4 code 44137 removed from Covered Codes Table. Removed deleted CPT4 code 47134 from Covered Codes Table. Removed incorrect ICD9 procedure code 50.5 from Covered Codes Table. Removed Non-Covered Codes Table.
08/23/2011: Policy description updated. Policy statement revised to add a not medically necessary statement. Deleted outdated references from the Sources section. Policy guidelines updated regarding patient selection criteria. Moved HIV-positive patient selection criteria from the Policy section to the Policy Guidelines section.
07/17/2012: Policy reviewed; no changes.
11/15/2013: Policy statement updated to add the following: A small bowel/liver retransplant or multivisceral retransplant may be considered medically necessary after a failed primary small bowel/liver transplant or multivisceral transplant.
09/01/2015: Code Reference section updated for ICD-10.
12/31/2015: Code Reference section updated to add CPT code 47399.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)Blue Cross Blue Shield Association policy #7.03.04
Blue Cross Blue Shield Association policy #7.03.05
Blue Cross Blue Shield Association policy #7.03.06
United Network for Organ Sharing
CODE REFERENCEThis may not be a comprehensive list of procedure 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.