TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation

This policy addresses isolated small bowel, combined small bowel/liver, and multivisceral transplantation. Coverage is medically necessary for adults and children with short bowel syndrome or irreversible intestinal failure who have failed total parenteral nutrition (TPN) and meet general selection criteria; TPN failure includes impending/overt TPN‑induced liver failure, thrombosis of two or more major central veins, or frequent line-related sepsis (≥2 hospitalization-requiring episodes/year). Not covered when the patient can tolerate TPN; living-donor small bowel transplant is not covered if a cadaveric graft is available, and all other indications (including pseudotumor peritonei) and living-donor multivisceral transplants are investigational; candidates must also have no absolute AST transplant contraindications (e.g., metastatic cancer).

"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 parente..."