Effective Date: This policy will apply to all services performed on or after the above effective date.

QualChoice maintains a national network of Centers of Excellence for members who require transplantation.
 

Transplants and transplant related services are covered only when performed at a transplant center previously approved by QualChoice.

1.    Intestinal or Multi-Visceral transplantation requires pre-authorization.

2.    QualChoice covers intestinal transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure who have severe complications of total parenteral nutrition.  

3.    QualChoice covers combined small bowel/liver transplantation in patients who require intestinal transplantation and have impending liver failure.

4.    QualChoice covers multi-visceral transplantation for patients with combined organ failure.

1.    Small Bowel Transplant:

QualChoice may authorize a small bowel transplant for a pediatric or adult Member meeting ALL of the following criteria:

a)     Irreversible intestinal failure

b)    Total parenteral nutrition (TPN) dependency established for a minimum of 2 years, or implementation of this requirement puts the Member at an unacceptably increased risk for a catastrophic event.

c)    Severe complications of TPN, including at least one of the following:

                        i.         Liver dysfunction

                       ii.         Frequent line infection and sepsis, either:

1)                  Two or more episodes of systemic sepsis secondary to line infection per year that requires hospitalization, OR

2)                  A single episode of line related fungemia, septic shock, and/or Acute Respiratory Distress Syndrome

                      iii.         Thrombosis of two or more or the jugular, subclavian, or femoral veins

                     iv.         Venous access difficulty with TPN

d)    Satisfactory psychosocial and support systems in place

2.    Simultaneous Small Bowel-Liver Transplant:

QualChoice may authorize a simultaneous small bowel/liver transplant for a pediatric or adult Member when ALL the following criteria are met:

a.    Irreversible intestinal failure

b.    Total parenteral nutrition (TPN) dependency established for a minimum of 2 years, or implementation of this requirement puts the Member at an unacceptably increased risk for a catastrophic event.

c.     Evidence of impending liver failure, including both of the following:

                                       i.     Prolonged prothrombin time

                                      ii.     Decreasing albumin level

d.    Severe complications of TPN including at least one of the following:

                                       i.     Liver dysfunction

                                      ii.     Frequent line infection and sepsis, either:

1)    Two or more episodes of systemic sepsis secondary to line infection per year that requires hospitalization, OR

2)    A single episode of line related fungemia, septic shock, and/or Acute Respiratory Distress Syndrome

                                     iii.     Thrombosis of two or more or the jugular, subclavian, or femoral veins

                                    iv.     Venous access difficulty with TPN

e.    Satisfactory psychosocial and support systems in place

3.    Multi-visceral Transplant:

QualChoice may authorize multivisceral transplants in Members with SBS when long term TPN results in impending liver failure and other complications (e.g., pancreatic failure, thrombosis of the celiac axis and superior mesenteric artery and/or pseudo obstruction affecting the entire GI tract).

Codes Used In This BI:

QualChoice will not authorize small bowel, combined small bowel/liver, or multivisceral transplantation for members with ANY of the following:

1.    Systemic disease affecting multiple body systems, including but not limited to scleroderma, amyloidosis, or diffuse atheromatous disease

2.    Malignancy, other than non-melanomatous skin cancer, within the last five years

3.    Any unresolved psychosocial concerns or history of noncompliance with medical management

1. Presence of other GI diseases (e.g., bleeding peptic ulcer, diverticulitis, chronic hepatitis)

5.    Serious health condition that creates the inability to tolerate the transplant surgery or post transplant medical regimen adherence, such as multisystem organ failure, cerebral edema, and/or severe cardiopulmonary disease.

6.    Active drug, substance, or alcohol abuse within the last 6 months

7.    Active tobacco use within the last 6 months such as actively smoking cigarettes, or using any nicotine delivery system products (e.g., gum, patches, electronic cigarettes)

8.    Uncontrolled or untreatable infection, any source

9.    Human immunodeficiency virus (HIV) infection unless ALL of the following are met:

a.    CD4 count greater than 200 cells/mm3

b.    Undetectable HIV-1 ribonucleic acid (RNA)

c.     Stable anti-retroviral therapy for > than three months

d.    Absence of serious complications associated with or secondary to HIV disease (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidioidomycosis, resistant fungal infections; Kaposi’s sarcoma; or other neoplasm)

1)    National Coverage Determination for Intestinal and Multi-Visceral Transplantation.  Centers for Medicare & Medicaid Services.  NCD 260.5  Accessed at CMS.gov on 23 October 2013.

2)    American Gastroenterological Association. American Gastroenterological Association Medical Position Statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003; 124(4):1105-10.

3)    Bhagani S, Sweny P, Brook G; British HIV Association.(2006) Guidelines for kidney transplantation in patients with HIV disease. HIV Med. 2006;7(3):133-139.

4)    Benedetti E, Holterman M, Asolati M et al.(2006) Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg 2006; 244(5):694-699.