Medical Policy

 

Subject: Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
Document #: TRANS.00013 Publish Date:    12/27/2017
Status: Reviewed Last Review Date:    11/02/2017

Description/Scope

This document addresses small bowel, small bowel/liver and multivisceral transplantation. A small bowel transplant, also known as intestinal transplant, is typically performed on individuals with short bowel syndrome or intestinal failure. 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.

Note: Please see the following for additional information:

Position Statement

Medically Necessary:

A small bowel transplant using cadaveric intestine is considered medically necessary for adults and children with short bowel syndrome or irreversible intestinal failure who have failed total parenteral nutrition (TPN) and meet the general individual selection criteria listed below.

TPN failure is defined when any one of the following is met:

  1. Impending or overt liver failure due to TPN induced liver injury. (Clinical indicators include: increased serum bilirubin or liver enzyme levels, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding, hepatic fibrosis, or cirrhosis); or
  2. Thrombosis of two or more major central venous channels (subclavian, jugular, or femoral veins). Thrombosis of two or more of these vessels is considered a life-threatening complication and TPN failure; or
  3. Frequent central line-related sepsis. Two or more episodes of line-induced systemic sepsis per year that require hospitalization are considered TPN failure. A single episode of line-related fungemia, septic shock, or acute respiratory distress syndrome is considered TPN failure; or
  4. Frequent episodes of severe dehydration despite TPN and intravenous fluid supplement. Under certain medical conditions such as secretory diarrhea and non-constructable gastrointestinal tract, the loss of combined gastrointestinal and pancreatobiliary secretions exceed the maximum intravenous infusion rates that can be tolerated by the cardiopulmonary system.

A small bowel transplant using a living donor may be considered medically necessary only when a cadaveric intestine is not available for transplantation in an individual who meets the criteria noted above for a cadaveric intestinal transplant.

Combined small bowel/liver transplants from deceased donors are considered medically necessary for adults and children who meet criteria for intestinal transplant and have overt or imminent liver failure or anatomical abnormalities which preclude an isolated small bowel transplant.

Multivisceral transplants from deceased donors are considered medically necessary for adults and children who meet criteria for the combined small bowel/liver transplant and require one or more abdominal visceral organs to be transplanted due to concomitant organ failure or anatomical abnormalities which preclude a small bowel/liver transplant.

Retransplantation in individuals with graft failure of an initial small bowel, small bowel/liver, or multivisceral transplant, due to either technical reasons or hyperacute rejection is considered medically necessary.

Retransplantation in individuals with chronic rejection or recurrent disease is considered medically necessary when the individual meets general selection criteria as defined below.

Not Medically Necessary:

A small bowel transplant in adults or children is considered not medically necessary for those who can tolerate TPN.

A small bowel transplant using a living donor in adults or children is considered not medically necessary when a cadaveric intestine is available for transplantation.

Investigational and Not Medically Necessary:

All other small bowel transplants in adults or children are considered investigational and not medically necessary.

Living donor multivisceral transplants in adults or children are considered investigational and not medically necessary.

All other multivisceral transplants in adults or children are considered investigational and not medically necessary.

General Individual Selection Criteria

In addition to having one of the clinical indications above, the individual must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.

Absolute Contraindications for Transplant Recipients include, but are not limited to, the following:

  1. Metastatic cancer
  2. Ongoing or recurring infections that are not effectively treated
  3. Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery
  4. Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured
  5. Demonstrated patient noncompliance, which places the organ at risk by not adhering to medical recommendations
  6. Potential complications from immunosuppressive medications are unacceptable to the patient
  7. Acquired immune deficiency syndrome (AIDS) (diagnosis based on Centers for Disease Control and Prevention (CDC) definition of CD4 count, 200cells/mm3) unless the following are noted:
    1. CD4 count greater than 200cells/mm3 for greater than 6 months
    2. HIV-1 RNA undetectable
    3. On stable anti-retroviral therapy greater than 3 months
    4. No other complications from AIDS (for example, opportunistic infection, including aspergillus, tuberculosis, coccidioide-mycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm)
    5. Meeting all other criteria for small bowel or multivisceral transplantation

Steinman, Theodore, et al. Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation. Transplantation. Vol. 71, 1189-1204, No. 9, May 15, 2001.

Rationale

Intestinal failure is a malabsorptive condition characterized by the inability of the gastrointestinal tract to maintain adequate nutrition, fluid and electrolyte balance for normal growth and development of the body (Bhamidimarri, 2014; Mangus, 2013). A common cause of intestinal failure is short bowel syndrome (SBS). Intestinal failure or SBS may result from extensive surgical resection for various indications, including but not limited to: volvulus; atresias; necrotizing enterocolitis; Crohn's disease; gastroschisis; thrombosis of the superior mesenteric artery; desmoid tumors; or trauma. Other causes of intestinal failure include motility disorders (for example, Hirschsprung’s disease, visceral neuropathy, and chronic pseudo-obstruction); malabsorptive disorders (for example, microvillus inclusion); as well as intestinal secretory disorders. Individuals with intestinal failure are unable to maintain adequate nutrition orally or with enteral tube feedings and as a result, intravenous total parenteral nutrition (TPN) is utilized to provide essential nutrients, vitamins, lipids, and fluids. However, long-term use of TPN may fail, resulting in life-threatening complications and a need for surgical intervention or small bowel transplant/intestinal transplant.

Intestinal transplants mainly utilize organs from deceased donors. However, there have been rare cases of using a portion of the intestine from a living-related donor for small bowel transplant. Smith and colleagues (2016) reported that in the United States, six living donor intestinal transplants occurred in 2004 and one occurred in 2014. It has been proposed that the theoretical advantages of a living donor intestinal transplant include elimination of waiting time, the ability to plan the transplantation electively, better tissue matching, and short cold ischemia time (Tzvetanov, 2010). The number of living donor small bowel transplants performed to date has been small and published literature is mostly limited to single-center individual case reports and small case series (Benedetti, 2006; Gangemi, 2009; Ji G, 2009; Li, 2008). However, small bowel transplants using a living donor may have a role in select cases where a cadaveric intestine is not available.

Combined small bowel/liver transplants may be a treatment option in individuals with intestinal failure and irreversible liver disease (Middleton 2005; Vianna, 2008). This procedure has been more commonly used in pediatric cases where TPN liver disease has been more of a problem than with adults (Middleton, 2005).

Multivisceral transplantation is a complex procedure requiring extensive hospitalization and is associated with late mortality and lengthy complications. Although the procedure is uncommon, there is continuing experience with the operation which appears to be life saving with 5-year survival rates in the 30-50% range. Consequently, multivisceral transplantation is an option for the specific subset of individuals who have been managed with long-term TPN and show signs of impending end-stage liver failure, as this is a potentially life-saving treatment.

In an Intestinal Transplant Registry report, Grant and colleagues (2005) analyzed data for intestine, small bowel/liver and multivisceral transplants performed from April 1985 to May 31, 2003, to determine the scope and success of these transplantations. All known intestinal transplant programs were included. Transplant recipient and graft survival estimates were obtained and analyzed. A total of 61 programs provided data on 989 grafts in 923 recipients. The data demonstrated 1-year graft/recipient survival rates of 65%/77% for intestinal grafts, 59%/60% for small-bowel and liver grafts, and 61%/66% for multivisceral grafts. The 1-year overall graft/recipient survival rates were 57.6%/64.7% for cadaveric grafts versus 59.3%/66.7% for living donor grafts.

Ten years after the last published Intestinal Transplant Registry report, Grant and colleagues (2015) examined more recent transplant activity. Clinical practices and outcomes were observed to be similar worldwide with only a few differences, and indications for intestinal transplant did not change over time. A total of 82 transplant programs reported 2887 transplants in 2699 recipients. Current actuarial survival rates are 76% at 1 year, 56% at 5 years and 43% at 10 years. No improvement was noted for rates of graft loss beyond 1 year.

Abu-Elmagd and colleagues (2009) reported on 500 intestinal and multivisceral transplants performed at a single center. The authors noted that the best outcomes in their series were intestine/liver allografts with a 1- and 5-year survival rate of 92% and 70%.

Ueno and colleagues (2010) analyzed the current status of intestinal transplantation based on findings reported at a 2009 international small bowel transplant symposium. In 2008, approximately 200 intestinal transplants were reported as being performed throughout the world with over 73 centers having participated in intestinal transplantation internationally. Intestinal transplants performed consisted of isolated intestinal transplantation, intestinal and liver transplantation, and multivisceral transplantation. Improvement in short-term post-transplant survival was seen. Isolated intestinal transplant recipients had a survival rate of approximately 80% at 1 year. In contrast to short-term survival, the long-term prognosis of transplant recipients did not demonstrate significant improvement. Five-year survival was reported as being approximately 20% before 1990, increasing to over 40% in the early 2000s, with no improvement seen during the past 10 years in “conditional 5-year survival for the patients who survived the first year.” Post-transplant complications included: post-transplant lymphoproliferative disease (PTLD), graft-versus-host disease (GVHD), and increased risk of infectious disease after stoma closure. PTLD rates have decreased in the past decade to 7% for isolated intestinal transplants and 8% for multivisceral transplants. GVHD was reported in approximately 5% of intestinal transplant recipients, which is a higher incidence than for other solid organ transplants. The increased risk of infectious disease after stoma closure was cited as a reason for lack of improvement in long-term prognosis of these transplant recipients. Conclusions made by the authors included that intestinal transplantation has saved the lives of those threatened by the complications of chronic TPN, short-term survival has improved remarkably, and improvements in long term survival and quality of life still need to be made.

Mangus and colleagues (2013) performed a retrospective case review of 95 individuals who underwent 100 multivisceral transplantations with or without a liver at a single U.S. center. There were 24 pediatric and 76 adult recipients. One-year survival was 72% and 3-year survival was 57%. A learning curve was noted by the authors, with a 48% survival rate for transplants performed between 2004 and 2007 and a 70% survival rate for those performed between 2008 and 2010.

In 2014, Lauro and colleagues reported on a single-center Italian case series of 45 transplant recipients who received either intestinal transplants alone or a combined transplant procedure. Twelve of the recipients had small bowel/multivisceral transplants. Five of these had the procedure due to short-bowel syndrome, 2 had chronic intestinal pseudo-obstruction, and 5 had Gardner syndrome. Survival rates for the entire transplant group were 77% at 1 year, 58% at 3 years, 53% at 5 years, and 37% at 10 years.

Small bowel, small bowel/liver and multivisceral transplants have been shown to be an effective option for individuals meeting specific criteria including when other treatment modalities such as TPN have failed; however, there is currently a paucity of published evidence in the peer-reviewed medical literature to support the safe and effective use of these transplants for other indications including, but not limited to individuals who can tolerate TPN.

Background/Overview

Possible types of transplants which include the small bowel are: isolated small bowel, combined small bowel/liver, and multivisceral transplant. The choice of transplant graft is made on a case-by-case basis depending on anatomy and disease process (Kubal, 2015). The most common of these procedures is the isolated small bowel (intestinal) transplantation (Beyer-Berjot, 2012). An isolated small bowel transplant usually involves the removal of the small intestine from a deceased donor, removal of the recipient’s small intestine, and replacement with the donor’s intestine. If a living donor is used, a segment of the donor’s small intestine is transplanted. A small bowel transplant is intended to restore adequate nutrition in individuals with short bowel syndrome. This is a condition in which the absorbing surface of the small intestine is nonfunctional due to extensive disease or surgical removal of a large portion of the small intestine.

Evidence of intolerance or failure of TPN includes, but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications, or the development of progressive but reversible liver failure. In the event of progressive liver failure, small bowel transplant may be considered a technique to avoid end stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.

A small bowel/liver transplant involves the transplantation of a cadaveric small intestine and liver into a recipient. Small bowel/liver transplants are typically performed for individuals with short bowel syndrome and concurrent liver failure or anatomical abnormalities.

A multivisceral transplant typically includes the small bowel/liver, in combination with one or more other abdominal visceral organ such as the stomach, pancreas or colon which may be transplanted due to concomitant organ failure or anatomical abnormalities. The most common indications for multivisceral transplantation are total occlusion of the splanchnic circulation, extensive gastrointestinal polyposis, hollow visceral myopathy or neuropathy, and some abdominal malignancies.

Definitions

Cadaver: The physical remains of a deceased person.

Short bowel syndrome: A malabsorption syndrome resulting from a significantly reduced small intestine.

Total parenteral nutrition (TPN): A method of supplying nourishment to children and adults who are unable to eat.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT

 

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

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 two 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 two partial liver grafts (i.e., left lobe (segments II, III, and IV) and right lobe (segments I and V through VIII)

47146

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

47147

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

48551

Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery

48552

Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each

 

 

HCPCS

 

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

 

 

ICD-10 Procedure

 

0DT80ZZ

Resection of small intestine, open approach

0FT00ZZ

Resection of liver, open approach

0FTG0ZZ

Resection of pancreas, open approach

0DY60Z0

Transplantation of stomach, allogeneic, open approach

0DY60Z1

Transplantation of stomach, syngeneic, open approach

0DY80Z0

Transplantation of small intestine, allogeneic, open approach

0DY80Z1

Transplantation of small intestine, syngeneic, open approach

0DYE0Z0

Transplantation of large intestine, allogeneic, open approach

0DYE0Z1

Transplantation of large intestine, syngeneic, open approach

0FY00Z0

Transplantation of liver, allogeneic, open approach

0FY00Z1

Transplantation of liver, syngeneic, open approach

0FYG0Z0

Transplantation of pancreas, allogeneic, open approach

0FYG0Z1

Transplantation of pancreas, syngeneic, open approach

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

Peer Reviewed Publications:

  1. Abu-Elmagd KM, Costa G, Bond GJ, et al. Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg. 2009; 250(4):567-581.
  2. Benedetti E, Holterman M, Asolati M, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg. 2006; 244(5):694-699.
  3. Beyer-Berjot L, Joly F, Dokmak S, et al. Intestinal transplantation: indications and prospects. J Visc Surg. 2012; 149(6):380-384.
  4. Bhamidimarri KR, Beduschi T, Vianna R. Multivisceral transplantation: where do we stand? Clin Liver Dis. 2014; 18(3):661-674.
  5. Freeman RB Jr, Steffick DE, Guidinger MK, et al. Liver and intestine transplantation in the United States, 1997-2006. Am J Transplant. 2008; 8(4 Pt 2):958-976.
  6. Gangemi A, Benedetti E. Living donor small bowel transplantation: literature review 2003-2006. Pediatr Transplant. 2006; 10(8):875-878.
  7. Gangemi A, Tzvetanov IG, Beatty E, et al. Lessons learned in pediatric small bowel and liver transplantation from living-related donors. Transplantation 2009; 87(7):1027-1030.
  8. Garcia Aroz S, Tzvetanov I, Hetterman EA, et al. Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience. Pediatr Transplant. 2017; 21(4).
  9. Grant D, Abu-Elmagd K, Mazariegos G, et al; Intestinal Transplant Association. Intestinal transplant registry report: global activity and trends. Am J Transplant. 2015; 15(1):210-219.
  10. Grant D, Abu-Elmagd K, Reyes J, et al. Intestine Transplant Registry. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. 2005; 241(4):607-613.
  11. Gupte GL, Beath SV, Protheroe S, et al. Improved outcome of referrals for intestinal transplantation in the UK. Arch Dis Child. 2007; 92(2):147-152.
  12. Ji G, Chu D, Wang W, Dong G. The safety of donor in living donor small bowel transplantation-an analysis of four cases. Clin Transplant. 2009; 23(5):761-764.
  13. Kato T, Selvaggi G, Gavnor J, et al. Expanded use of multivisceral transplantation for small children with concurrent liver and intestinal failure. Transplant Proc. 2006; 38(6):1705-1708.
  14. Kato T, Tzakis AG, Selvaggi G, et al. Intestinal and multivisceral transplantation in children. Ann Surg. 2006; 243(6):756-766.
  15. Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep. 2015; 17(1):427.
  16. Lauro A, Zanfi C, Dazzi A, et al. Disease-related intestinal transplant in adults: results from a single center. Transplant Proc. 2014; 46(1):245-248.
  17. Li M, Ji G, Feng F, et al. Living-related small bowel transplantation for three patients with short gut syndrome. Transplant Proc. 2008; 40(10):3629-3633.
  18. Mangus RS, Tector AJ, Kubal CA, et al. Multivisceral transplantation: expanding indications and improving outcomes. J Gastrointest Surg. 2013; 17(1):179-186.
  19. Middleton SJ, Jamieson NV. The current status of small bowel transplantation in the UK and internationally. Gut. 2005; 54(11):1650-1657.
  20. Moon JI, Tzakis AG. Intestinal and multivisceral transplantation. Yonsei Med J. 2004; 45(6):1101-1106.
  21. Ruiz P, Kato T, Tzakis A. Current status of transplantation of the small intestine. Transplantation. 2007; 83(1):1-6.
  22. Smith JM, Skeans MA, Horslen SP, et al. Intestine. Am J Transplant. 2016; 16 Suppl 2:99-114.
  23. Tzakis AG, Kato T, Nishida S, et al. The Miami experience with almost 100 multivisceral transplants. Transplant Proc. 2006; 38(6):1681-1682.
  24. Tzvetanov IG, Oberholzer J, Benedetti E. Current status of living donor small bowel transplantation. Curr Opin Organ Transplant. 2010; 15(3):346-348.
  25. Ueno T, Fukuzawa M. Current status of intestinal transplantation. Surg Today. 2010; 40(12):1112-1122.
  26. Vianna RM, Mangus RS, Tector AJ. Current status of small bowel and multivisceral transplantation. Adv Surg. 2008; 42:129-150.
  27. Vianna RM, Mangus RS. Present prospects and future perspectives of intestinal and multivisceral transplantation. Curr Opin Clin Nutr Metab Care. 2009; 12(3):281-286.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003; 124(4):1105-1110.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Intestinal and multivisceral transplantation. NCD# 260.5. Effective May 11, 2006. Available at: http://www.cms.hhs.gov/mcd/index_chapter_list.asp. Accessed on September 5, 2017.
  3. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant. 2001; 5(2):80-87.
Websites for Additional Information
  1. Intestinal Transplant Association. Available at: http://www.intestinaltransplant.org/. Accessed on September 5, 2017.
  2. Organ Procurement and Transplantation Network (OPTN). Available at: http://optn.transplant.hrsa.gov/. Accessed on September 5, 2017.
  3. Scientific Registry of Transplant Recipients. Available at: http://www.srtr.org. Accessed on September 5, 2017.
  4. United Network for Organ Sharing (UNOS). Available at: http://www.unos.org. Accessed on September 5, 2017.
Index

Intestinal Transplant
Small Bowel Transplant
Small Bowel/Liver Transplant
Multi-visceral Transplant
Total Parenteral Nutrition
TPN

Document History

Status

Date

Action

Reviewed

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated form “Current Effective Date” to “Publish Date”. References section updated.

Revised

11/03/2016

MPTAC review. Abbreviation defined in position statement. Formatting updated in position statement in “absolute contraindications for transplant recipients” section. Description, Rationale, Background and Reference sections updated.

Reviewed

11/05/2015

MPTAC review. Rationale and Reference sections updated. Removed ICD-9 codes from Coding section.

Reviewed

11/13/2014

MPTAC review. Description, Rationale and Reference sections updated.

Reviewed

11/14/2013

MPTAC review. Description, Background and Reference sections updated.

Reviewed

11/08/2012

MPTAC review. Background and Reference sections updated.

Reviewed

11/17/2011

MPTAC review. Description, Rationale and References updated.

Reviewed

11/18/2010

MPTAC review. Title, Rationale, Background, Definitions, References, and Index updated.

Revised

11/19/2009

MPTAC review. Initial medically necessary statement for small bowel transplant revised from addressing deceased or living donors to the use of a cadaveric intestine. A medically necessary statement for a small bowel transplant using a living donor and a not medically necessary for living donor small bowel transplantation was added. Rationale, background, references, and web sites for additional information updated.

Reviewed

05/21/2009

MPTAC review. Rationale, references and background updated.

Revised

05/15/2008

MPTAC review. Medically necessary statement revised. Description, rationale, background, definitions, coding, and references updated.

Revised

02/21/2008

MPTAC review. References and background updated. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.” This change was approved at the November 29, 2007 MPTAC meeting. Added a separate header for the “Not Medically Necessary” statement. Revisions made to the “Medically Necessary”, “Not Medically Necessary” and the “Investigational and Not Medically Necessary” statements.

Revised

03/08/2007

MPTAC review. Medical necessity statement revised. Updated rationale, references and coding.

Reviewed

03/23/2006

MPTAC review. References updated.

 

11/18/2005

Added reference for Centers for Medicare & Medicaid Services (CMS) -National Coverage Determination (NCD).

Revised

04/28/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

09/18/2003

TRANS.00012

Small Bowel Transplant

 

09/18/2003

TRANS.00013

Multivisceral Transplant Including Small Bowel and Liver

WellPoint Health Networks, Inc.

09/23/2004

7.06.04

Small Bowel Transplant

 

09/23/2004

7.06.06

Small Bowel/Liver and Multivisceral Transplantation