Organ Transplant Policy Comparison
I.
Small Bowel
2/8/2016
Full Coverage Details
BCBS
A.) A small bowel transplant using
cadaveric intestine may be considered
medically necessary in adult and pediatric
patients with intestinal failure (characterized
by loss of absorption and the inability to
maintain protein-energy, fluid, electrolyte, or
micronutrient balance), who have established
long-term dependency on total parenteral
nutrition (TPN) and are developing or have
developed severe complications due to TPN.
B) A small bowel transplant using a living
donor may be considered medically
necessary only when a cadaveric intestine is
not available for transplantation in a patient
who meets the criteria for a cadaveric
intestinal transplant.
B.) Small bowel/liver transplant or
multivisceral transplant may be considered
medically necessary in 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 who have
been managed with total parenteral nutrition
(TPN) and have developed evidence of
impending end-stage liver failure.
Medicaid
a. Short bowel syndrome, with documented long-term TPN therapy
and severe complications from TPN
b. Multiple and prolonged hospitalizations to treat TPN-related
complications
c. Progressive, reversible liver failure
d. A small bowel/liver multi-visceral transplant with short bowel
syndrome with documented long-term TPN therapy with
development of impending end stage liver failure
Organ Transplant Policy Comparison
II.


Small Bowel
2/8/2016
Coverage Exclusion
BCBS
When the criteria listed above has
not been met.
A small bowel transplant is
considered investigational for
adults who are able to tolerate
TPN. BCBSNC does not cover
investigational services.
Medicaid
4.1 Non-Covered Conditions The N.C. Medicaid program does not
cover small bowel (intestinal), small bowel/liver, and multivisceral
transplants when one of the following conditions exists (not all inclusive):
a. Cardiovascular disease (ejection fraction < 40%, myocardial infarction
within last six months)
b. Age greater than 70 years old
c. Psychosocial history that would limit ability to comply with medical
care pre- and post-transplant
d. Current patient and/or caretaker non-compliance that would make
compliance with a disciplined medical regime improbable
e. History of or active substance abuse—must have documentation of
substance abuse program completion plus six months of negative
sequential random drug screens *Note: To satisfy the requirement for
sequential testing as designated in this policy, the Division of Medical
Assistance (DMA) must receive a series of test (alcohol and drug) results
spanning a minimum six-month period, allowing no fewer than a threeweek interval and no more than six-week interval between each test during
the given time period. A complete clinical packet for prior approval must
include at least one documented test performed within one month of the
date of request to be considered.
f. HIV positive
g. Multi-organ failure
h. Congenital immunodeficiency
i. Advanced neurological disorders (neuroaxonal dystrophy, Tay-Sachs,
Niemann-Pick disease, etc.)
j. Chronic hepatitis
k. Malignancy (primary or metastatic) patients with a history of cancer
with remission less than 5 years
l. Combining bone marrow infusion with intestinal allograft irradiation to
prevent allograft rejection
4.2 Donors
Living donor expenses are not covered for a small bowel or multi-visceral
transplant.
Organ Transplant Policy Comparison
III.
Small Bowel
2/8/2016
BCBS Policy Guidelines
Cases requesting approval for transplants will be reviewed to determine medical necessity according to the Plan
as outlined in this policy provided the certificate does not exclude benefits for Small Bowel Transplant, Small
Bowel with Liver, or Multivisceral.
IV.
Medicaid Policy Guidelines
None.