BlueCross and BlueShield of Montana Medical Policy/Codes
Small Bowel Transplant
Chapter: Transplant
Current Effective Date: October 25, 2013
Original Effective Date: September 04, 2009
Publish Date: October 25, 2013
Revised Dates: April 16, 2012; December 7, 2012; September 27, 2013
Description

SBT involves the removal of the small intestine from a donor, removal of the recipient's organ and transplantation with the donor's intestine. The surgery can have different donor sources of either cadaveric or a living donor. 

SBT is meant to treat patients with short bowel syndrome (SBS). This condition involves an insufficient amount of absorptive area needed to maintain adequate nutrition.  It can occur as a result of extensive disease or surgical removal of large portion of the small intestine. Multiple etiologies exist for SBS such as:

  • Atresia;
  • Crohn's disease;
  • Desmoid tumors;
  • Gastroschisis;
  • Mesenteric artery thrombus;
  • Necrotizing enterocolitis;
  • Trauma;
  • Volvulus.

Complications associated with long term TPN therapy include:

  • Catheter associated problems;
  • Hepatobiliary disease;
  • Infections;
  • Metabolic bone disease.
Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Small bowel transplantation (SBT) is considered medically necessary for patients (adults and children) with: 

  • Short bowel syndrome (SBS) with dependency on long term total parenteral nutrition (TPN); AND
  • Severe complications (i.e. hepatobiliary disease, multiple infections, or metabolic bone disease) due to TPN. 

SBT is considered experimental or investigational for adults able to tolerate TPN and without complications.

SBT using living donors is considered experimental or investigational for adults and children.

Rationale

SBT is a treatment of last resort for end stage intestinal failure due to extreme cases of SBS and nutrition dependent TPN therapy.

In 2001, Abu-Elmagd and colleagues evaluated the results of a 130 intestinal transplants from the Pittsburgh Intestinal Transplant Registry performed between May 1990 and May 1999. Review of the data showed a 1 year patient survival rate of 72% and a 5 year patient survival rate of 48%. The reported graft survival rate for 1 year and 5 years was 72% and 40%. The years of 1995 to 1999, revealed 63 transplants performed with a cumulative allograft survival rate of 65%. This increase was attributed to refinements made in operative techniques, immunosuppressive therapy and management strategies.

Farmer and associates (2001) retrospectively examined intestinal transplants performed between August 1991 and December 2000. During this time, 21 intestinal grafts were transplanted into 17 recipients. All the donors were cadaveric, matched by blood group and body size. The patient survival rates for 1 and 3 years was 63% and 55% correspondingly. A graft survival rate at 1 and 3 years was 73% and 55% respectively.

Review of clinical literature for living related SBT revealed a few small studies. Fujimoto et al (2000) reports on 2 cases of SBT using living related donors. SBT was used in 2 pediatric patients with SBS. Patient 1 died 16 months after SBT from pneumocystic carinii pneumonia and patient 2 was reported alive and off all TPN in 2000. Data for living donor SBT remains limited.

With improvements being made with patient and graft survival rates, SBT has the potential to become part of the standard of care for patients with end stage intestinal failure.     

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

45.62, 45.63, 46.97, 579.3

ICD-10 Codes
K90.0-K90.9, K91.2, 0DY80Z0 
Procedural Codes: 44120, 44121, 44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86849, S2053, S2054, S2055, S2152
References
  1. Agency for Health Care Policy and Research, Health Technology Review. Small Intestine and Combined Liver-Small Bowel Transplantation. Number 5 (August 1993): 1-5.
  2. Small Bowel Transplants in Adults and Multivisceral Transplants in Adults and Children. BCBSA TEC Assessment Program (1999 July) 14(9): 1-17.
  3. Fujimoto, Y., Uemoto, S., et al Small bowel transplantation using grafts from living related donors. Two case reports. Transplant International (2000) 13 Supplement 1:S179-184.
  4. Small Bowel Transplant. BCBSA Consortium Health Plan Medical Policy Reference Manual (2000 November 3) Surgery: 7.03.04.
  5. Abu-Elmagd, K., Reyes, J., et al. Clinical Intestinal Transplantation: Recent Advances and Future Consideration. Primer on Transplantation (2001) Chapter 80: 610-625.
  6. Farmer, D., McDiarmid, S., et al. Outcome after intestinal transplantation: results from one center's 9 year experience; discussion 1031-1032. Archives of Surgery (2001 September) 136(9): 1027-1031.
History
April 2012 Potential contraindications added to Policy Guidelines. Wording of potential contraindications consistent with other solid organ transplant policies. Investigational statement added to policy. Updated references and rationale. Reworded title to specifically say "Isolated" Small Bowel Transplant.
December 2012 Policy updated with literature review. Added references 7 and 8; other references renumbered. No change in policy statements.
October 2013 Policy formatting and languague revised.  Policy statement unchanged.  Title changed from "Isolated Small Bowel Transplant" to "Small Bowel Transplant".
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Small Bowel Transplant