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Date Printed: October 17, 2017: 04:19 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-40000-19

Original Effective Date: 09/01/01

Reviewed: 07/24/14

Revised: 01/01/16

Subject: Small Bowel, Liver and Multivisceral Transplant

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Small bowel/liver transplantation is transplantation of an intestinal allograft in combination with a liver allograft, either alone or in combination with one or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.

Small bowel transplants are typically performed in individuals with short bowel syndrome, defined as an inadequate absorbing surface of the small intestine due to congenital defect, extensive disease or surgical removal of a large portion of small intestine. In some instances, short bowel syndrome is associated with liver failure, often due to the long-term complications of total parenteral nutrition (TPN). These individuals may be candidates for a small bowel/liver transplant or a multivisceral transplant, which includes the small bowel and liver with 1 or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, and/or colon. A multivisceral transplant is indicated when anatomic or other medical problems preclude a small bowel/liver transplant.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Small Bowel, Liver and Multivisceral Transplant to expedite the medical review process.

1. Click the link Solid Organ Transplant - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

A small bowel/liver transplant or multivisceral transplant meets the definition of medical necessity for pediatric and adult individuals who meet ALL of the following:

A small bowel/liver transplant or multivisceral transplant meets the definition of medical necessity in HIV [human immunodeficiency virus]-positive candidates who meet ALL of the following:

A small bowel/liver retransplant or multivisceral retransplant meets the definition of medical necessity after a failed primary small bowel/liver transplant or multivisceral transplant.

A small/bowel/liver transplant or multivisceral transplant is considered experimental or investigational for all other indications.

Potential contraindications to small bowel/liver transplant or multivisceral transplant (subject to the judgment of the transplant center) include:

Transplant associated services which meet the definition of medical necessity include:

BILLING/CODING INFORMATION:

CPT Coding:

44120

Enterectomy, resection of small intestine, single resection and anastomosis

44121

Each additional resection and anastomosis

44132

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

44133

Donor enterectomy (including cold preservation), open; partial, 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

47133

Donor hepatectomy (including cold preservation), from cadaver donor

47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age

47140

Donor hepatectomy, with preparation and maintenance of allograft, from living donor; left lateral segment only (segments II and III)

47141

Donor hepatectomy, with preparation and maintenance of allograft, from living donor; total left lobectomy (segments II, III and IV)

47142

Donor hepatectomy, with preparation and maintenance of allograft, from living donor; total right lobectomy (segments V, VI, VII and VIII)

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 thorough VIII])

47146

Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each

47147

Backbench reconstruction of dacafer or living donor liver graft prior to allotransplantation; arterial anastomosis, each

HCPCS Coding:

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

REIMBURSEMENT INFORMATION:

Please refer to the specific contractual agreements with the applicable transplant facility or to the global rates of the applicable transplant network.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Intestinal and Multi-Visceral Transplantation (260.5) located at cms.gov.

DEFINITIONS:

Crohn’s disease: chronic granulomatous inflammatory disease involving the gastrointestinal tract, commonly involving the terminal ileum with scarring and thickening of the bowel wall, frequently leading to intestinal obstruction and fistula and abscess formation, with high rate of recurrence after treatment.

Desmoid tumor: a fibrous or fibroid tumor arising in the muscle sheath.

Enteral nutrition: tube feeding by way of the small intestine.

Enterectomy: excision of a part of the intestine; resection of the intestine.

Enterocolitis: inflammation involving the small intestine and colon.

Gastroschisis: a congenital fissure of the abdominal wall not involving the site of insertion of the umbilical cord, and usually accompanied by protrusion of the small intestine and part of the large intestine.

Hepatobiliary: pertaining to the liver and the bile or the biliary ducts.

Heterotopic: appearing at an abnormal place or upon the wrong part of the body.

Intestinal atresia: congenital obstruction or closure of an orifice or tubular organ (i.e., intestine).

Metabolic bone disease: disease of the bone caused by disruption of a normal metabolic pathway because of a genetically determined enzyme defect.

Multivisceral: many organs, especially of the abdomen.

Necrotizing: changes indicative of cell death caused by progressive deteriorating action of enzymes, affecting groups of cells or part of a structure or organ.

Orthotopic: pertaining to a tissue transplant grafted into its normal anatomical position.

Parenteral nutrition: nutrition administered by injection by a route other than orally, such as subcutaneous, intramuscular, intravenous, etc.

Thrombosis: the presence, development, or formation of a blood clot.

Volvulus: intestinal obstruction due to knotting or twisting of the bowel.

RELATED GUIDELINES:

Liver Transplant, 02-40000-20
Pancreas Transplantation, 02-40000-17

Small Bowel Transplant, 02-40000-18

OTHER:

None applicable.

REFERENCES:

  1. American Gastroenterological Association medical position statement: Short Bowel Syndrome and Intestinal Transplantation. Gastroenterology 2003 Apr; 124(4): 1105-10 (reviewed annually). (Accessed 06/22/14).
  2. American Society of Transplantation (AST): Key Position Statements. Accessed 05/22/08.
  3. Blue Cross Blue Shield Association Medical Policy Small Bowel/Liver and Multivisceral Transplant 7.03.05 (June 2014).
  4. Blue Cross Blue Shield Association TEC Assessments (1994, Tab # 15; 1999, Tab # 9).
  5. Centers for Medicare and Medicaid Services (CMS), National Coverage Determination for Intestinal and Multi-Visceral Transplantation, Publication 100-3, Section 260.5 (05/11/06).
  6. Harrison E, Allan P, Ramu A, Vaidya A, Travis S, Lal S. (2014). Management of intestinal failure in inflammatory bowel disease: Small intestinal transplantation or home parenteral nutrition? World journal of gastroenterology: WJG, 20(12), 3153.
  7. HAYES Inc. Medical Technology Directory; Small Bowel-Liver and Multivisceral Transplants Lansdale, PA: Hayes, Inc; 02/28/05; updated 04/10/08.
  8. HCFA (CMS) Medicare Program Memorandum Transmittal AB-00-58, Intestinal Transplantation (04/12/01).
  9. Mangus RS, Tector AJ, Kubal CA, Fridell JA, Vianna RM. Multivisceral transplantation: expanding indications and improving outcomes. J Gastrointest Surg. 2013 Jan;17(1):179-86; discussion p.186-7.
  10. National Institutes for Health; Kidney and Liver Transplants in People with HIV (02/04).
  11. National Institute for Health and Care Excellence (NICE). Interventional Procedure Guidance (IPG) 194: Living-donor liver transplantation. May 2006. Accessed at http://www.nice.org.uk on 06/22/14.
  12. 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.
  13. Ordonez F, Barbot-Trystram L, Lacaille F, Chardot C, Ganousse S, Petit LM, Colomb-Jung V, Dalodier E, Salomon J, Talbotec C, Campanozzi A, Ruemmele F, RĂ©villon Y, Sauvat F, Kapel N, Goulet O. Intestinal absorption rate in children after small intestinal transplantation. Am J Clin Nutr. 2013 Apr;97(4):743-9.
  14. Organ Procurement and Transplantation Network. Policy Management. Accessed at http://optn.transplant.hrsa.gov/policiesAndBylaws/policies.asp on 06/22/14.
  15. Trevizol AP, David AI, Yamashita ET, Pecora RA, D'Albuquerque LA. Intestinal and multivisceral retransplantation results: literature review. Transplant Proc. 2013 Apr;45(3):1133-6.
  16. United Network for Organ Sharing Policies and bylaws (2004).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/24/14.

GUIDELINE UPDATE INFORMATION:

09/01/01

Coding changes.

03/15/02

Medical Coverage Guideline Reviewed; no changes.

01/01/04

Annual HCPCS coding update.

03/15/04

Reviewed; added information regarding transplants in HIV-positive recipients.

01/01/05

HCPCS coding update; added new codes for small bowel and liver transplantation.

06/15/05

Revision to guideline, consisting of removal of investigational statement regarding HIV-positive recipients.

06/15/06

Scheduled review; no change in coverage statement.

06/15/07

Scheduled review (consensus); no change in coverage statement; reformatted guideline; updated references.

07/15/08

Scheduled review; add intestinal failure language to position statement, updated references.

01/01/09

Annual HCPCS coding update: descriptor revised for codes 47144 and 47145.

07/15/09

Scheduled review; no change to position statement.

01/01/10

Annual HCPCS coding update: revise descriptors for CPT codes 47144 & 47145.

10/15/10

Revision; related ICD-10 codes added.

05/11/14

Revision: Program Exceptions section updated.

08/15/14

Scheduled review. Revised description, position statement and CPT coding. Updated references.

01/01/16

Annual CPT/HCPCS coding update. Deleted code 47136.

Date Printed: October 17, 2017: 04:19 PM