Archived Policies - Surgery
Liver, Small Bowel, and Multivisceral Transplants
A liver and small bowel or multivisceral transplant is considered medically necessary for adult and pediatric patients with short bowel syndrome (SBS) under the following circumstances:
The use of a living donor as the source of small bowel in a combined liver and small bowel transplant or multivisceral transplant is considered experimental or investigational.
Liver and small bowel transplantation includes the removal of the liver or lobe of the liver and small intestine from a donor (cadaveric or living) with transplantation into the recipient. In some cases, SBS is connected with liver failure, secondary to long term complications of TPN. These patients may be candidates for small bowel and liver transplant or a multivisceral transplant. A multivisceral transplant includes the liver, small bowel, and one or more of the following organs:
A multivisceral transplant is indicated when anatomic or other medical problems prevent a liver and small bowel transplant and may be seen with the following conditions:
Liver and small bowel and multivisceral transplantation are treatments of last resort for patients afflicted with SBS and impending end stage liver failure. In 2001, Abu-Elmagd and colleagues reported on 165 intestinal allografts (received by 155 patients) over a 10 year period at the University of Pittsburgh Medical Center. Of the 165 allografts reported, 75 were given as liver and small bowel combinations and 25 as multivisceral. The review noted that the recipients of liver/small bowel allografts "had the best prognosis for continued survival beyond 5 years" with a graft survival rate at 50 %. A 1999 TEC Assessment reviewed the topic of multivisceral transplantation. The summary statement acknowledged multivisceral transplantation is associated with early postoperative complications with late mortality requiring extensive hospitalization. Although an uncommon surgery, it appears life saving with 5 year survival rates between 30% to 50% and without the surgery, patients face a 100% mortality rate.
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.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
44120, 44121, 44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721, 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86849
S2053, S2054, S2055, S2152
ICD-9 Diagnosis Codes
579.3 with 070.0, 070.1, 070.20 to 070.33, 070.40 to 070.49, 070.50 to 070.59, 070.6, 070.9, 121.1, 121.3, 155.0, 270.0 to 270.9, 272.0 to 272.9, 275.0, 275.1, 277, 277.3, 277.6, 277.9, 285.0, 356.0, 357.4 (with 277.3), 453.0, 459.9, 570, 571.0 to 571.9, 573.1 to 573.3, 576.1, 576.2, 576.8, 751.61, 751.62, 864.00 to 864.19, V59.6
ICD-9 Procedure Codes
45.61 to 45.63, 46.97, 50.22, 50.4, 50.51, 50.59
ICD-10 Diagnosis Codes
ICD-10 Procedure Codes
Multiple Organ Transplant. Medicare Part B Newsletter (1993 March 1) #340.
Small Intestine and Combined Liver-Small Intestine Transplantation. Agency for Health Care Policy and Research, Health Technology Review (1993 August) 5: 1-5.
Small Bowel/Liver and Multivisceral Transplant. BCBSA Consortium Health Plan Medical Policy Reference Manual (1995 December 1) Surgery: 7.03.05.
Small Bowel Transplants in Adults and Multivisceral Transplants in Adults and Children. BCBSA TEC Assessment (1999 July) 9(14): 1-18.
Abu-Elmagd, K., Reyes, J., et al. Clinical Intestinal Transplantation: A Decade of Experience at a Single Center. Annals of Surgery (2001 April 26) 234(3): 404-417.
Liver and Intestine Transplantation. The United Network for Organ Sharing Chapter VII (2002). (Web site accessed: 09/22/2003). http://www.unos.org/data/ar2002/ar02_chapter_seven.htm.
|Title:||Effective Date:||End Date:|
|Small Bowel/Liver and Multivisceral Transplant||10-15-2018||02-14-2020|
|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|