Medical Policy: 07.03.05
Original Effective Date: November 2009
Reviewed: November 2015
Revised: November 2015
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.
Combined Small Bowel and Liver Transplant
Combined small bowel and liver transplant is generally indicated when intestinal failure is accompanied by irreversible liver failure, usually due to the long term complications of total parenteral nutrition (TPN).
Intestinal failure results from obstruction, dysmotility, 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 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 balances when on a conventionally accepted, normal diet.
Leading causes of intestinal failure differ between adult and pediatric populations. In children, the following are the leading causes of intestinal failure:
The following are the leading causes of intestinal failure in adults:
The chronic use of TPN is often associated with life-threatening complication including:
Multivisceral Transplant
Multivisceral transplant is generally indicated when anatomic or other medical problems preclude a small bowel/liver transplant when intestinal failure is accompanied by liver failure, usually due to complications of long term total parenteral nutrition (TPN). In addition, the patient usually has a history surgery, abdominal trauma, motility disorders, tumor or other etiologies that warrant the multivisceral transplant. The multivisceral transplant can include the liver, stomach, small intestine (duodenum, jejunum and ileum), pancreas and/or colon. Kidney transplant may also be included if the recipient has end stage renal failure.
Retransplantation
The most common causes of graft loss may include acute and chronic rejection,
post- transplant lymphoproliferative disorder, graft dysmotility or dysfunction, severe infection, arterial graft aneurysm or allograft liver failure. Careful patient selection,
post-transplant immunosuppression and patient management are essential for successful long-term outcomes. Individuals undergoing retransplantgation for small bowel and liver or multivisceral transplantation should meet all of the eligibility criteria for primary transplantation and should not have contraindications to transplantation.
Summary
Evidence for combined small bowel/liver and multivisceral transplant and retransplant consists of case series. Though infrequently performed, the transplant procedures are demonstrated to provide a survival benefit, and the procedure is considered medically necessary for patients who have been managed with long-term parenteral nutrition and who have developed evidence of impending end stage liver failure.
Practice Guideline and Position Statement
In 2003, the American Gastroenterological Association produced a medical position statement on short bowel syndrome and intestinal transplantation. It recommends dietary, medical and surgical solutions. Indications for intestinal transplant mirror those of Medicare in patients who fail TPN therapy for one of the following reasons:
Until better data become available, these parameters are likely to be widely recognized as the indications for intestinal transplantation.
Prior approval is required. Submit a prior approval now.
A combined small bowel and liver transplant may be considered medically necessary for pediatric and adult patients with intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance) who have been managed with long-term total parenteral nutrition (TPN) and who have developed evidence of impending end-stage liver failure.
A multivisceral transplant may be considered medically necessary for pediatric and adult patients who meet criteria above for the combined small bowel and liver transplant and require 1 or more abdominal visceral organs to be transplanted due to concomitant organ failure or anatomical abnormalities that preclude a small bowel and liver transplant.
A combined small bowel and liver transplant or multivisceral transplant for pediatric and adult patients performed for any other conditions not listed above will be considered not medically necessary.
Retransplant
A combined small bowel and liver retransplant or multivisceral retransplant may be considered medically necessary after failed primary combined small bowel and liver transplant or multivisceral transplant provided the individual meets the transplant criteria above.
Except as defined above, candidates for small bowel and liver or multivisceral transplants should meet the following general criteria:
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:
It is likely that each individual transplant center will have explicit patient selection criteria for HIV-positive patients.
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and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.