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Medical Policy: 07.03.04
Original Effective Date: November 2009
Reviewed: April 2011
Revised: April 2011
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Small bowel transplants are generally 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. Etiologies of short bowel syndrome include volvulus, atresias, necrotizing enterocolitis, Crohn’s disease, gastroschisis, thrombosis of the superior mesenteric artery, desmoid tumors, and trauma. Patients with short bowel syndrome are dependent on total parenteral nutrition (TPN). Those who develop intestinal failure or complications or intolerance of TPN and can no longer be maintained on TPN may be considered candidates for small bowel transplant. Complications of TPN include catheter-related mechanical problems, infections, hepatobiliary disease, and metabolic bone disease. Intolerance of TPN may be evidenced by 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 means to avoid end-stage liver failure, thus avoiding a multivisceral organ transplant.
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Prior Approval:
Prior approval is recommended. Submit a prior approval now.
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Policy:
A small bowel transplant using a cadaveric intestine may be considered medically necessary in adult and pediatric patients with intestinal failure who have established long-term dependency on TPN and are developing or have developed severe complications due to TPN.
Small bowel transplant using a living donor intestine may be considered medically necessary for patients meeting the above criteria when a cadaveric intestine is not available for transplantation.
A small bowel transplant is considered investigational for adults with intestinal failure who are able to tolerate TPN.
Except as defined above, candidates for small bowel/liver and multivisceral transplants should meet the following general criteria:
- Adequate cardiopulmonary status
- Absence of active infection
- Documentation of patient compliance with medical management
The evaluation of a transplant candidate who has a history of cancer must consider the prognosis and risk of recurrence from available information including tumor type and stage, response to therapy, and time since therapy was completed. Although evidence is limited, patients in whom cancer is thought to be cured should not be excluded from consideration for transplant. UNOS has not addressed malignancy in current policies.
The United Network for Organ Sharing (UNOS) believes that asymptomatic HIV-positive patients should not necessarily be excluded for candidacy for organ transplantation, stating, “A potential candidate for organ transplantation whose test for HIV is positive but who is in an asymptomatic state should not necessarily be excluded from candidacy for organ transplantation, but should be advised that he or she may be at increased risk of morbidity and mortality because of immunosuppressive therapy.” In 2001, the Clinical Practice Committee of the American Society of Transplantation proposed that the presence of AIDS could be considered a contraindication to kidney transplant unless the following criteria were present. These criteria may be extrapolated to other potential organ transplants:
- CD4 count ≥ 200 cells/mm-3 for > 6 months
- HIV-1 RNA undetectable
- On stable anti-retroviral therapy > 3 months
- No other complications from AIDS (e.g., opportunistic infection including aspergillus, tuberculosis, coccidioses mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm)
- Meeting all other criteria for organ transplantation
It is likely that each individual transplant center will have explicit patient selection criteria for HIV-positive patients.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 44132; Donor enterectomy (including cold preservation), open; from cadaver donor
- 44135; Intestinal allotransplantation; from cadaver donor
- 44715; Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein
- 44720; Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each
- 44721; Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each
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Selected References:
- Steinman TI, Becker BN, Frost AE et al. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation 2001; 71(9):1189-204.
- O’Keefe SJ, Buchman AL, Fishbein TM et al. Short bowel syndrome and intestinal failure: consensus definitions and overview. Clin Gastroenterol Hepatol 2006; 4(1): 6-10.
- American Gastroenterological Association. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003 Apr;124(4):1105-10.
- Tzvetanov IG, Oberholzer J, Benedetti E. Current status of living donor small bowel transplantation. Curr Opin Organ Transplant. 2010 Jun;15(3):346-8.
- Gangemi A, Tzvetanov IG, Beatty E et al. Lessons learned in pediatric small bowel and liver transplantation from living-related donors. Transplantation. 2009 Apr 15;87(7):1027-30.
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Policy History:
Date Reason Action
April 2011 Annual review Revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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