632 Form

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Medical Policy Small Bowel/Liver and Multivisceral Transplant Table of Contents
• Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • References
• Coding Information

Policy Number: 632 BCBSA Reference Number: 7.03.05 (For Plan internal use only) Related Policies
Isolated Small Bowel Transplant, #631 Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

A small bowel/liver transplant or multivisceral transplant may be MEDICALLY NECESSARY for pediatric and adult patients with intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance) who have been managed with long-term total parenteral nutrition (TPN) and who have developed evidence of impending end-stage liver failure.

A small bowel/liver retransplant or multivisceral retransplant may be MEDICALLY NECESSARY after a failed primary small bowel/liver transplant or multivisceral transplant.

In addition to the above information, we do not cover small bowel/liver transplant or multivisceral transplantation when any of the following conditions are present: • Known current malignancy, including metastatic cancer • Recent malignancy with high risk of recurrence o Note: the assessment of risk of recurrence for a previously treated malignancy is made by the transplant team; providers must submit a statement with an explanation of why the patient with a recently treated malignancy is an appropriate candidate for a transplant. • History of cancer with a moderate risk of recurrence • Systemic disease that could be exacerbated by immunosuppression • Untreated systemic infection making immunosuppression unsafe, including chronic infection o Other irreversible end-stage disease not attributed to intestinal failure • Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Candidates should meet the following criteria: • Adequate cardiopulmonary status • Documentation of patient compliance with medical management.

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HIV [human immunodeficiency virus]-positive patients who meet the following criteria, as stated in the 2001 guidelines of the American Society of Transplantation, could be considered candidates for small bowel/liver or multivisceral transplantation: • CD4 count greater than 200 cells per cubic millimeter for greater than 6 months • HIV-1 RNA undetectable • On stable anti-retroviral therapy >3 months • No other complications from AIDS [acquired immune deficiency syndrome] (e.g., opportunistic infection, including aspergillus, tuberculosis, coccidiosis mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm), and meeting all other criteria for transplantation.

A small/bowel/liver transplant or multivisceral transplant is INVESTIGATIONAL in all other situations.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This procedure is performed in the inpatient setting. Commercial PPO and Indemnity This procedure is performed in the inpatient setting. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes HCPCS Codes HCPCS codes: Code Description S2053 Transplantation of small intestine and liver allografts S2054 Transplantation of multivisceral organs
ICD-10 Procedure Codes CPT codes: Code Description 44135 Intestinal allotransplantation; from cadaver donor 44136 Intestinal allotransplantation; from living donor 47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age

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ICD-10-PCS procedure codes: Code Description 0DY60Z0 Transplantation of Stomach, Allogeneic, Open Approach 0DY60Z1 Transplantation of Stomach, Syngeneic, Open Approach 0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach 0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach 0DY80Z0 Transplantation of Small Intestine, Allogeneic, Open Approach 0DY80Z1 Transplantation of Small Intestine, Syngeneic, Open Approach 0FY00Z1 Transplantation of Liver, Syngeneic, Open Approach 0FY00Z0 Transplantation of Liver, Allogeneic, Open Approach 0DT80ZZ Resection of Small Intestine, Open Approach 0DT84ZZ Resection of Small Intestine, Percutaneous Endoscopic Approach 0DYE0Z0 Transplantation of Large Intestine, Allogeneic, Open Approach 0DYE0Z1 Transplantation of Large Intestine, Syngeneic, Open Approach

Description Solid organ transplantation offers a treatment option for patients with different types of end-stage organ failure that can be lifesaving or provide significant improvements to a patient’s quality of life.1, Many advances have been made in the last several decades to reduce perioperative complications. Available data supports improvement in long-term survival as well as improved quality of life, particularly for liver, kidney, pancreas, heart, and lung transplants. Allograft rejection remains a key early and late complication risk for any organ transplantation. Transplant recipients require life-long immunosuppression to prevent rejection. Patients are prioritized for transplant by mortality risk and severity of illness criteria developed by Organ Procurement and Transplantation Network and United Network of Organ Sharing.

Small Bowel/Liver and Multivisceral Transplant In 2024, 48,149 transplants were performed in the United States procured from 41,119 deceased donors and 7030 living donors.2, Intestinal transplants occur less frequently than other organ transplants, with 10 or fewer patients receiving liver-intestine transplant each year from 2008 to 2019. Small bowel and liver or multivisceral transplant is usually considered in adults and children who develop serious complications related to parenteral nutrition, including inaccessibility (eg, due to thrombosis) of access sites, catheter- related sepsis, and cholestatic liver disease.

Short Bowel Syndrome Short bowel syndrome is defined as an inadequate absorbing surface of the small intestine due to extensive disease or surgical removal of a large portion of the small intestine.3, In some instances, short bowel syndrome is associated with liver failure, often due to the long-term complications of total parenteral nutrition.

Treatment A small bowel/liver transplant or a multivisceral transplant includes the small bowel and liver with 1 or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, and/or colon. The type of transplantation depends on the underlying etiology of intestinal failure, quality of native organs, presence or severity of liver disease, and history of prior abdominal surgeries.4, A multivisceral transplant is indicated when anatomic or other medical problems preclude a small bowel/liver transplant. Complications following small bowel/liver and multivisceral transplants include acute or chronic rejection, donor-specific antibodies, infection, lymphoproliferative disorder, graft-versus-host disease, and renal dysfunction.5,

Summary This evidence review addresses transplantation and retransplantation of an intestinal allograft in combination with a liver allograft, either alone or in combination with 1 or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.

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For individuals who have intestinal failure and evidence of impending end-stage liver failure who receive a small bowel and liver transplant alone or multivisceral transplant, the evidence includes a registry study and a limited number of case series. Relevant outcomes are overall survival (OS), morbid events, and treatment-related mortality and morbidity. These transplant procedures are infrequently performed and few reported case series exist. However, results from the available literature have revealed fairly high postprocedural survival rates. Given these results and the exceedingly poor survival rates of patients who exhaust all other treatments, transplantation may prove not only to be the last option but also a beneficial one. Transplantation is contraindicated for patients in whom the procedure is expected to be futile due to comorbid disease, or in whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have a failed small bowel and liver or multivisceral transplant without contraindications for retransplant who receive a small bowel and liver retransplant alone or multivisceral retransplant, the evidence includes case series. Relevant outcomes are OS, morbid events, and treatment-related mortality and morbidity. Although limited in quantity, the available post retransplantation data have suggested reasonably high survival rates. Given exceedingly poor survival rates without retransplantation of patients who have exhausted other treatments, evidence of postoperative survival from uncontrolled studies is sufficient to demonstrate that retransplantation provides a survival benefit in appropriately selected patients. Retransplantation is contraindicated for patients in whom the procedure is expected to be futile due to comorbid disease or in whom posttransplantation care is expected to significantly worsen comorbid conditions. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 11/2025 Annual policy review. Policy updated with literature review through July 23, 2025; no references added. Policy statements unchanged. 10/2024 Annual policy review. Policy updated with literature review through July 8, 2024; no references added. Policy statements unchanged. 10/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2021 Annual policy review. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
10/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2017 Annual policy review. New references added. 1/2017 Annual policy review. New references added. 1/2016 Clarified coding information. 8/2015 Coding information clarified. 10/2014 Medical policy remediation: New indications for non-coverage. Coding information clarified. Effective 10/1/2014. 4/2014 Coding information clarified. 12/2013 Annual policy review. New medically necessary indications described. Effective 12/1/2013. Coding information clarified. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements. 5/2012 Annual policy review. Changes to policy statements.

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11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 10/2010 Annual policy review. No changes to policy statements. 6/2010 Annual policy review. Changes to policy statements. 11/2009 Annual policy review. Changes to policy statements. 11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 5/2009 Annual policy review. No changes to policy statements. 11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Black CK, Termanini KM, Aguirre O, et al. Solid organ transplantation in the 21 st century. Ann Transl Med. Oct 2018; 6(20): 409. PMID 30498736
2. Organ Procurement and Transplantation Network (OPTN). National Data. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/. Accessed July 23, 2025.
3. Sulkowski JP, Minneci PC. Management of short bowel syndrome. Pathophysiology. Feb 2014; 21(1): 111-8. PMID 24341969
4. Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf). Feb 2017; 5(1): 20-28. PMID 28130374
5. Loo L, Vrakas G, Reddy S, et al. Intestinal transplantation: a review. Curr Opin Gastroenterol. May 2017; 33(3): 203-211. PMID 28282321
6. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Small bowel transplants in adults and multivisceral transplants in adults and children. TEC Assessments. 1999;Volume 14:Tab
8. Mangus RS, Tector AJ, Kubal CA, et al. Multivisceral transplantation: expanding indications and improving outcomes. J Gastrointest Surg. Jan 2013; 17(1): 179-86; discussion p.186-7. PMID 23070622
9. 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. Oct 2009; 250(4): 567-81. PMID 19730240
10. Desai CS, Khan KM, Gruessner AC, et al. Intestinal retransplantation: analysis of Organ Procurement and Transplantation Network database. Transplantation. Jan 15 2012; 93(1): 120-5. PMID 22113492
11. Raghu VK, Beaumont JL, Everly MJ, et al. Pediatric intestinal transplantation: Analysis of the intestinal transplant registry. Pediatr Transplant. Dec 2019; 23(8): e13580. PMID 31531934
12. Lacaille F, Irtan S, Dupic L, et al. Twenty-eight years of intestinal transplantation in Paris: experience of the oldest European center. Transpl Int. Feb 2017; 30(2): 178-186. PMID 27889929
13. 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. Jun 2017; 21(4). PMID 28295952
14. Dore M, Junco PT, Andres AM, et al. Surgical Rehabilitation Techniques in Children with Poor Prognosis Short Bowel Syndrome. Eur J Pediatr Surg. Feb 2016; 26(1): 112-6. PMID 26535775
15. Rutter CS, Amin I, Russell NK, et al. Adult Intestinal and Multivisceral Transplantation: Experience From a Single Center in the United Kingdom. Transplant Proc. Mar 2016; 48(2): 468-72. PMID 27109980
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): 245-8. PMID 24507060

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16. Varkey J, Simrén M, Bosaeus I, et al. Survival of patients evaluated for intestinal and multivisceral transplantation - the Scandinavian experience. Scand J Gastroenterol. Jun 2013; 48(6): 702-11. PMID 23544434
17. Spence AB, Natarajan M, Fogleman S, et al. Intra-abdominal infections among adult intestinal and multivisceral transplant recipients in the 2-year post-operative period. Transpl Infect Dis. Feb 2020; 22(1): e13219. PMID 31778012
18. Nagai S, Mangus RS, Anderson E, et al. Cytomegalovirus Infection After Intestinal/Multivisceral Transplantation: A Single-Center Experience With 210 Cases. Transplantation. Feb 2016; 100(2): 451-
19. PMID 26247555
20. Timpone JG, Yimen M, Cox S, et al. Resistant cytomegalovirus in intestinal and multivisceral transplant recipients. Transpl Infect Dis. Apr 2016; 18(2): 202-9. PMID 26853894
21. Wu GS, Cruz RJ, Cai JC. Acute antibody-mediated rejection after intestinal transplantation. World J Transplant. Dec 24 2016; 6(4): 719-728. PMID 28058223
22. Cromvik J, Varkey J, Herlenius G, et al. Graft-versus-host Disease After Intestinal or Multivisceral Transplantation: A Scandinavian Single-center Experience. Transplant Proc. 2016; 48(1): 185-90. PMID 26915866
23. Florescu DF, Qiu F, Langnas AN, et al. Bloodstream infections during the first year after pediatric small bowel transplantation. Pediatr Infect Dis J. Jul 2012; 31(7): 700-4. PMID 22466325
24. Wu G, Selvaggi G, Nishida S, et al. Graft-versus-host disease after intestinal and multivisceral transplantation. Transplantation. Jan 27 2011; 91(2): 219-24. PMID 21076376
25. Organ Procurement and Transplantation Network (OPTN). Organ Procurement and Transplantation Network Policies. Updated June 26, 2025; https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed July 22, 2025.
26. Working Party of the British Transplantation Society. Kidney and Pancreas Transplantation in Patients with HIV. Second Edition (Revised). British Transplantation Society Guidelines. Macclesfield, UK: British Transplantation Society; 2017.
27. Ekser B, Kubal CA, Fridell JA, et al. Comparable outcomes in intestinal retransplantation: Single-center cohort study. Clin Transplant. Jul 2018; 32(7): e13290. PMID 29782661
28. Mazariegos GV, Soltys K, Bond G, et al. Pediatric intestinal retransplantation: techniques, management, and outcomes. Transplantation. Dec 27 2008; 86(12): 1777-82. PMID 19104421
29. American Gastroenterological Association. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. Apr 2003; 124(4): 1105-10. PMID 12671903
30. Iyer K, DiBaise JK, Rubio-Tapia A. AGA Clinical Practice Update on Management of Short Bowel Syndrome: Expert Review. Clin Gastroenterol Hepatol. Oct 2022; 20(10): 2185-2194.e2. PMID 35700884
31. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant. Apr 2001; 5(2): 80-7. PMID 11328544
32. Center for Medicare & Medicaid Services. National Coverage Determination (NCD) for Intestinal and Multi- Visceral Transplantation (260.5). 2006; https://www.cms.gov/medicare-coverage- database/details/ncd- details.aspx?NCDId=280. Accessed July 23, 2025.