Intestinal and Multivisceral Transplant

This policy covers intestinal and multivisceral transplantation—including isolated intestinal and combined liver‑intestinal transplants—for pediatric and adult members with irreversible intestinal failure (eg, severe short bowel syndrome, TPN failure or TPN‑induced liver injury, extensive central venous thrombosis, recurrent line sepsis, severe GI motility disorders, or other specified indications). Coverage requires meeting the policy’s specific clinical criteria and having none of the contraindications (eg, active high‑risk malignancy, uncontrolled serious comorbidities, GFR <40 mL/min/1.73 m² unless considered for multi‑organ transplant, detectable HIV viral load, active substance use, recent major cardiac/stroke events, or septic shock); HIV candidates must have CD4 >200 cells/mm³ and be on effective ART.

"Intestinal and/or multivisceral transplantation is medically necessary for pediatric and adult members with irreversible intestinal failure when they meet the specific clinical criteria in section II."