CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Small Bowel, Small Bowel/Liver and Multivisceral Transplantation

Section: Surgery
Effective Date: November 01, 2019
Revised Date: October 02, 2019
Last Reviewed: September 26, 2019

Description

A small bowel transplant is performed to treat individuals with irreversible intestinal failure. Small bowel along with liver or multivisceral transplantation is for those individuals who have intestinal failure and have developed serious complications from long term use of total parenteral nutrition (TPN).

Criteria

A small bowel or small bowel/liver transplant or multivisceral transplant may be considered medically necessary for pediatric and adult individuals:

  • With intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance); or 
  • Who have been managed with long-term TPN and who have developed evidence of impending end-stage liver failure.

Evidence of intolerance to TPN including but not limited to the following:

  • Multiple and prolonged hospitalizations to treat TPN-related complications; or
  • The development of progressive but reversible liver failure.

Transplant candidates should meet the following criteria:

  • Adequate cardiopulmonary status; and
  • Absence of significant infection that could be exacerbated by immunosuppressive therapy (e.g., chronic active viral hepatitis B, hepatitis C, and human immunodeficiency virus [HIV]); and
  • No history of malignancy within five (5) years of transplantation, excluding non-melanomatous skin cancers; and
  • Documentation of individual’s compliance with medical management.

Absolute contraindications for transplant recipients include, but are not limited to, the following:

  • Metastatic cancer; or 
  • Ongoing or recurring infections that are not effectively treated; or 
  • Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery; or 
  • Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured; or 
  • Demonstrated individual’s noncompliance, which places the organ at risk by not adhering to medical recommendations; or 
  • Potential complications from immunosuppressive medications are unacceptable to the individual; or 
  • Acquired immune deficiency syndrome (AIDS) (diagnosis based on CDC definition of CD4 count, 200cells/mm3) unless the following are noted:
    • CD4 count greater than 200cells/mm3 for greater than six (6) months; and
    • HIV-1 RNA undetectable; and
    • On stable anti-retroviral therapy greater than three (3) months; and
    • No other complications from AIDS (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioide-mycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm); and 
    • Meeting all other criteria for small bowel or multivisceral transplantation.

Potential contraindications to solid organ transplant:

  • Known current malignancy, including metastatic cancer; or
  • Recent malignancy with high risk of recurrence; or 
  • History of cancer with a moderate risk of recurrence; or 
  • Systemic disease that could be exacerbated by immunosuppression; or 
  • Untreated systemic infection making immunosuppression unsafe, including chronic infection; or 
  • Other irreversible end-stage disease not attributed to intestinal failure; or 
  • Advanced neurological disorders; or
  • Multi-organ failure; or
  • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

Procedure Codes

44120 44121 44132 44133 44135 44136 44715
44720 44721 44799 47133 47135 47140 47141
47142 47143 47144 47145 47146 47147 47399
S2053 S2054 S2055

Retransplantation in individuals with graft failure of an initial small bowel, small bowel/liver, or multi-visceral transplant, due to technical reasons, hyper acute or chronic rejection, or return of the disease may be considered medically necessary if the clinical criteria of this policy have been met.

Procedure Codes

44120 44121 44132 44133 44135 44136 44715
44720 44721 44799 47133 47135 47140 47141
47142 47143 47144 47145 47146 47147 47399
S2053 S2054 S2055

Living donor multivisceral transplants in adults or children are considered not medically necessary.

Procedure Codes

44132 44133 47133 47135 47140 47141 47142
47143 47144 47145 47146 47147 47399 S2054

Small bowel, small bowel/liver or multivisceral transplantation performed for any other conditions than those listed in this policy or for individuals presenting with an absolute contraindication will be considered not medically necessary.

Procedure Codes

44120 44121 44132 44133 44135 44136 44715
44720 44721 44799 47133 47135 47140 47141
47142 47143 47144 47145 47146 47147 47399
S2053 S2054 S2055

Small bowel, small bowel/liver or multivisceral transplants are considered experimental/investigational for adults with intestinal failure who are able to tolerate TPN due to lack of supporting evidence.

Procedure Codes

44120 44121 44132 44133 44135 44136 44715
44720 44721 44799 47133 47135 47140 47141
47142 47143 47144 47145 47146 47147 47399
S2053 S2054 S2055

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

 Diagnosis Codes

K72.00 K72.01 K72.10 K72.11 K72.90 K72.91 K76.2
K90.0 K90.1 K90.2 K90.3 K90.49 K90.9 K90.81
K90.89 K91.2

Links