48552
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.19
Facility
$211.43
Non-Facility
$211.43
Documentation Required
- Refer to separate policy CP.MP.250 for criteria related to Lantidra (donislecel) allogeneic pancreatic islet cellular therapy.
- Serial blood and urine testing may be required to verify abstinence from substances of concern.
- Documentation of a commitment to reduce substance-use behaviors is acceptable when urgent transplant timelines exist (as evidence of risk-reduction intent).
- Chart notes, emergency department records, or hospitalization records documenting the recurrent severe metabolic complications and specifying the type (e.g., hypoglycemia unawareness, severe hypoglycemic attacks, marked hyperglycemia, recurrent ketoacidosis).
Key Coverage Criteria
- A small bowel transplant using cadaveric intestine is consideredmedically necessaryfor adults and children with short bowel syndrome or irreversible intestinal failure who have failed total parenteral nutrition (TPN)andmeet the general individual selection criteria listed below.
- TPN failure is defined when anyoneof the following is met:
- 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
- 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
- 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
- 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.
9 Active Policies
AMBETTER-CP.MP.102 — Pancreas Transplantation
ANTHEM-MP-A053824 — TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
ANTHEM-MP-A046252 — Pre-Merger Organizations
BCBSIL-SUR703.013 — Allogeneic Pancreas Transplant
BCBSMT-SUR703.013 — Allogeneic Pancreas Transplant
Related Codes
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