Archived Policies - Surgery
Liver-Small Bowel and Multivisceral Transplant
Coverage will be allowed for combined liver and small bowel transplantation for pediatric and adult patients with short bowel syndrome:
o Who have been managed with long-term TPN and
o Who have developed evidence of impending end-stage liver failure.
Coverage will not be allowed for multi visceral transplantation, as described above, for any age, as it is considered investigational.
A Liver-Small Bowel Transplant involves the removal of the liver and small intestine from a donor cadaver and implantation into the recipient. The liver-small bowel transplantation improves the health outcome of those patients with short bowel syndrome (SBS) who have been managed with long-term total parental nutrition (TPN) and have developed evidence of impending end-stage liver failure.
A Multi visceral Transplant includes the liver and small bowel and may include the stomach, duodenum, jejunum, ileum, pancreas, or colon. Multi visceral transplantation can be done for patients with the following conditions:
o Short bowel syndrome,
o Liver failure,
o Pancreatic failure, and/or
o Other gastrointestinal problems, such as
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Medicare Part B Newsletter, #340,
Agency for Health Care Policy and Research, Health Technology Review, Small Intestine and Combined Liver-Small Intestine Transplantation, Number 5, August 1993, pages 1-5.
NAC and BCBSA National Account Consortium Medical Policy Reference Manual, Small Bowel/Liver and Multi visceral Transplant, Surgery,
BCBSA TEC Bulletin, Transplants Involving the Small Bowel, December 12, 1995, Volume 12, Number 12, pages 32-34.
Search done on
|Title:||Effective Date:||End Date:|
|Small Bowel/Liver and Multivisceral Transplant||06-01-2017||10-14-2018|
|Small Bowel/Liver and Multivisceral Transplant||11-01-2016||05-31-2017|
|Small Bowel/Liver and Multivisceral Transplant||02-01-2016||10-31-2016|
|Small Bowel/Liver and Multivisceral Transplant||02-01-2014||01-31-2016|
|Liver, Small Bowel, and Multivisceral Transplants||07-01-2004||01-31-2014|
|Liver-Small Bowel and Multivisceral Transplant||03-01-2000||06-30-2004|