Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2013 Title: Intestinal or Multi-Visceral Transplant
Revision Date: Document: BI434:00
CPT Code(s): 44132,44133, 44135, 44136, 44715, 44720, 44721, S2053, S2054, S2055
Public Statement

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.


Medical Statement

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:

 

44132

Donor enterectomy (including cold preservation), open; from cadaver donor

44133

Donor enterectomy (including cold preservation), open; partial, from living donor

44135

Intestinal allotransplantation; from cadaver donor

44136

Intestinal allotransplantation; from living 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

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


Limits

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)


Background

Small bowel transplant is the transplantation of an intestinal allograft to an individual with irreversible intestinal failure to restore intestinal function. Intestinal failure is the inability of the small bowel to absorb adequate nutrition and fluids due to loss in length, function, and/or absorptive capacity of the small bowel, resulting in malabsorption, malnutrition, and dehydration. The most common cause of intestinal failure is short bowel syndrome (SBS) or short gut syndrome, a congenital disorder in which an infant`s intestine is too short or underdeveloped to allow normal food digestion. Other causes may include abdominal trauma, Crohn`s disease, thrombotic disorders and surgical adhesions.

Small bowel transplantation can be performed in one of three ways: alone, in combination with the liver, or multi-visceral (i.e., with one or more of the following: liver, pancreas, stomach, duodenum, intestine and colon).

Total parenteral nutrition (TPN) can produce long-term survival once small intestinal dysfunction makes oral nutrition ineffective. Complications resulting from TPN use may lead to serious morbidity and mortality.


Reference

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.

Gangemi A, Benedetti E.(2006) Living donor small bowel transplantation: literature review 2003-2006. Pediatr Transplant 2006;10(8):875-878.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.