S2053, Transplantation of small intestine and liver allografts
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of clinical indicators of failed TPN (examples provided): records showing frequent severe dehydration despite IV fluid supplement plus TPN; documentation of TPN-related complications (e.g., secretory diarrhea, non-constructible GI tract) leading to dehydration.
- Documentation of infections/line sepsis: hospital records documenting 2 or more episodes of systemic sepsis due to line infection per year requiring hospitalization, or documentation of a single episode of line-related fungemia, septic shock and/or acute respiratory distress syndrome.
- Documentation of liver injury from TPN: laboratory evidence such as elevated serum bilirubin and/or liver enzymes, and clinical signs such as splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or imaging/biopsy showing hepatic fibrosis/cirrhosis.
Key Coverage Criteria
- Aetna considers intestinal transplantation medically necessary for persons who have clinical indicators of failed total parenteral nutrition (TPN) when the selection criteria below are met.
- Clinical Indicators of Failed TPN: Frequent episodes of severe dehydration despite intravenous fluid supplement in addition to TPN.
- Clinical Indicators of Failed TPN: Frequent line infection and sepsis. The development of 2 or more episodes of systemic sepsis due to line infection per year that requires hospitalization indicates failure of TPN therapy. A single episode of line-related fungemia, septic shock and/or acute respiratory distress syndrome are considered indicators of TPN failure.
- Clinical Indicators of Failed TPN: Impending or overt liver failure due to TPN-induced liver injury. The clinical signs include elevated serum bilirubin and/or liver enzymes, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding or hepatic fibrosis/cirrhosis.
- Clinical Indicators of Failed TPN: Other complications leading to loss of vascular access.
- Clinical Indicators of Failed TPN: Thrombosis of the major central venous channels, jugular, subclavian, and femoral veins. Thrombosis of 2 or more of these vessels is considered a life-threatening complication and failure of TPN therapy.
8 Active Policies
ANTHEM-MP-A053824, TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
AETNA-CPB-0605, Intestinal Transplantation
AMBETTER-CP.MP.58, Intestinal and Multivisceral Transplant
SUR703.009, Small Bowel/Liver and Multivisceral Transplant
BCBSIL-SUR703.009, Small Bowel/Liver and Multivisceral Transplant
Related Codes
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