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Medical Policy: 07.03.05
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/liver transplantation is generally used for patients who have 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. Often these patients develop associated liver failure and can no longer be maintained on total parenteral nutrition (TPN).
In addition to intestinal failure, candidates for multivisceral transplant have developed liver failure, often as a complication of long-term TPN. These patients have a high predicted short-term mortality. They have also developed other gastrointestinal problems such as pancreatic failure, thromboses of the celiac axis and the superior mesenteric artery, or pseudo-obstruction affecting the entire gastrointestinal tract. In order to transplant the liver and the small bowel and restore gastrointestinal function, other organs must also be included in the transplant. Multivisceral transplantation can include the liver, stomach, duodenum, jejunum, ileum, pancreas, and/or colon.
As defined by the American Gastroenterological Association in 2003, a patient is considered to have failed TPN when any of the following conditions have been met:
- TPN-induced impending or overt liver failure as evidence by elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or hepatic fibrosis/cirrhosis
- Central line access failure, as evidenced by central venous thrombosis of two or more vessels, pulmonary embolism, superior vena cava syndrome, or chronic venous insufficiency
- Severe sepsis, as evidenced by two or more episodes of systemic sepsis secondary to line infection per year that requires hospitalization or a single episode of line-related fungemia, septic shock and/or acute respiratory distress syndrome (ARDS)
- Frequent episodes of severe dehydration despite intravenous fluid supplement in addition to TPN
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Prior Approval:
Prior approval is recommended. Submit a prior approval now.
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Policy:
A small bowel/liver transplant or multivisceral transplant may be considered medically necessary for pediatric and adult patients with intestinal failure who have been managed with long-term TPN and who have developed evidence of impending end-stage liver failure.
A small bowel/liver transplant or multivisceral transplant using a living donor intestine may be considered medically necessary for patients meeting the above criteria when a cadaveric transplant is not available for transplantation.
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.
There is minimal data regarding long-term outcomes of liver transplantation in HIV-positive patients. 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
- 44137; Removal of transplanted intestinal allograft, complete
- 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
- 47133; Donor hepatectomy (including cold preservation), from cadaver donor
- 47135; Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
- 47136; Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age
- 47143; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
- 47144; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (i.e., left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])
- 47145; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (i.e., left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII])
- 47146; Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each
- 47147; Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each
- 48550; Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation
- 48551; Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery
- 48552; Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each
- 48554; Transplantation of pancreatic allograft
- S2053; Transplantation of small intestine and liver allografts
- S2054; Transplantation of multivisceral organs
- S2055; Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donor
- S2152; Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor (s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre and posttransplant care in the global definition
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Selected References:
- Abu-Elmagd KM. Intestinal transplantation for short bowel syndrome and gastrointestinal failure: current consensus, rewarding outcomes, and practical guidelines. Gastroenterology. 2006 Feb; 130(2 Suppl 1): S132-7.
- American Gastroenterological Association. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003 Apr;124(4):1105-10.
- ECRI Institute. Hotline Response [database online]. Plymouth Meeting (PA): ECRI Institute; 2008 Oct 21. Intestine and Intestine-Liver Transplantation. Available at http://www.ecri.org.
- Kato T, Tzakis AG, Selvaggi G et al. Intestinal and multivisceral transplantation in children. Ann Surg. 2006 Jun;243(6):756-64.
- Bhagani S, Sweny P, Brook G; British HIV Association. Guidelines for kidney transplantation in patients with HIV disease. HIV Med. 2006; 7(3):133-9.
- Sudan DL. Treatment of intestinal failure: intestinal transplantation. Nat Clin Pract Gastroenterol Hepatol. 2007 Sep;4(9):503-10.
- Pironi L, Forbes A, Joly F et al. Survival of patients identified as candidates for intestinal transplantation: a 3-year prospective follow-up. Gastroenterology. 2008 Jul;138(1):61-71.
- 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
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and, therefore, cannot guarantee any results or outcomes.
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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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