BlueCross BlueShield of Tennessee Medical Policy Manual

Intestinal Transplantation

DESCRIPTION

Intestinal transplantation may be performed as an isolated small bowel transplant or in conjunction with other visceral organs, including the liver, duodenum, jejunum, ileum, pancreas, or colon, in individuals with intestinal failure. Intestinal failure is characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.

Isolated small bowel transplant is typically performed in individuals with short bowel syndrome.  This is a condition in which the absorbing surface of the small intestine is inadequate due to extensive disease or surgical removal of a large portion of the small intestine.  In adults, etiologies of short bowel syndrome include ischemia, trauma, volvulus and tumors.  In children, gastroschisis, volvulus, necrotizing enterocolitis and congenital atresias are predominant causes.  In individuals with progressive liver failure, a complication of long-term TPN use, a small bowel transplant may be considered a technique to avoid end-stage liver failure, thus avoiding the necessity of a multivisceral transplant.

A combined small bowel/liver transplant may be considered for children and adults with intestinal failure who have developed evidence of impending end-stage liver failure after long-term use of TPN.  A multivisceral transplant may be considered when anatomic or other medical problems preclude a small bowel/liver transplant.

POLICY

MEDICAL APPROPRIATENESS

NOTE:  Potential contraindications are subject to the judgment of the transplant center

      • Known current malignancy

      • History of malignancy with a moderate to high risk of recurrence

      • Irreversible end-stage disease not attributed to intestinal failure

      • Systemic disease or untreated systemic infection making immunosuppression unsafe

      • Psychosocial conditions or chemical dependence affecting ability to adhere to therapy

IMPORTANT REMINDER

SOURCES

American Gastroenterological Association. (2003, April). American Gastroenterological Association medical position statement: Short bowel syndrome and intestinal transplantation. Retrieved November 19, 2010 from http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS0016508503000520.pdf.

BlueCross BlueShield Association. Evidence Positioning System. (8:2018). Isolated small bowel transplant (7.03.04). Retrieved November 27, 2018 from www.evidencepositioningsystem.com/ (32 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Evidence Positioning System. (8:2018). Small bowel/liver and multivisceral transplant (7.03.05). Retrieved November 27, 2018 from www.evidencepositioningsystem.com/.  (25 articles and/or guidelines reviewed)

Center for Medicare and Medicaid Services. CMS.gov. National Coverage Determination (NCD) for intestinal and multi-visceral transplantation (260.5) Retrieved March 4, 2016 from https://www.cms.gov.

Ganousse-Mazeron, S., Lacaille, F., Colomb-Jung, V., Talbotec, C., Ruemmele, F., Sauvat, F., et al. (2015). Assessment and outcome of children with intestinal failure referred for intestinal transplantation. Clinical Nutrition, 34 (3), 428-435. Abstract retrieved December 28, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  4/1980

MOST RECENT REVIEW DATE:  1/10/2019  

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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