Medical Policy

This document addresses small bowel, small bowel/liver and multivisceral transplantation. A small bowel transplant, also known as intestinal transplant, is typically performed on individuals with short bowel syndrome or intestinal failure. In some instances, short bowel syndrome is associated with liver failure, often due to the long-term complications of total parenteral nutrition (TPN). These individuals may be candidates for a small bowel/liver transplant, or a multivisceral transplant.

Note: Please see the following for additional information:

• TRANS.00008 Liver Transplantation

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

A small bowel transplant using an intestine from a deceased donor is considered medically necessary for adults and children with short bowel syndrome or irreversible intestinal failure who have failed total parenteral nutrition (TPN) and meet the general individual selection criteria listed below.

TPN failure is defined when any one of the following is met:

1. Impending or overt liver failure due to TPN-induced liver injury. (Clinical indicators include: increased serum bilirubin or liver enzyme levels, splenomegaly, thrombocytopenia, gastroesophageal varices, coagulopathy, stomal bleeding, hepatic fibrosis, or cirrhosis); or
2. Thrombosis of two or more major central venous channels (subclavian, jugular, or femoral veins). Thrombosis of two or more of these vessels is considered a life-threatening complication and TPN failure; or
3. Frequent central line-related sepsis. Two or more episodes of line-induced systemic sepsis per year that require hospitalization are considered TPN failure. A single episode of line-related fungemia, septic shock, or acute respiratory distress syndrome is considered TPN failure; or
4. Frequent episodes of severe dehydration despite TPN and intravenous fluid supplementation. Under certain medical conditions such as secretory diarrhea and non-constructable gastrointestinal tract, the loss of combined gastrointestinal and pancreatobiliary secretions exceed the maximum intravenous infusion rates that can be tolerated by the cardiopulmonary system.

A small bowel transplant using a living donor may be considered medically necessary only when an intestine from a deceased donor is not available for transplantation in an individual who meets the criteria noted above for a deceased donor intestinal transplant.

Combined small bowel/liver transplants from deceased donors are considered medically necessary for adults and children who meet criteria for intestinal transplant and have overt or imminent liver failure or anatomical abnormalities which preclude an isolated small bowel transplant.

Multivisceral transplants from deceased donors are considered medically necessary for adults and children who meet criteria for the combined small bowel/liver transplant and require one or more abdominal visceral organs to be transplanted due to concomitant organ failure or anatomical abnormalities which preclude a small bowel/liver transplant.

Retransplantation in individuals with graft failure of an initial small bowel, small bowel/liver, or multivisceral transplant, due to either technical reasons or hyperacute rejection is considered medically necessary.

Retransplantation in individuals with chronic rejection or recurrent disease is considered medically necessary when the individual meets general selection criteria as defined below.

Not Medically Necessary:

A small bowel transplant in adults or children is considered not medically necessary for those who can tolerate TPN.

A small bowel transplant using a living donor in adults or children is considered not medically necessary when an intestine from a deceased donor is available for transplantation.

Investigational and Not Medically Necessary:

All other indications for small bowel or multivisceral transplants in adults or children, including but not limited to treatment of pseudomyxoma peritonei, are considered investigational and not medically necessary.

Living donor multivisceral transplants in adults or children are considered investigational and not medically necessary.

General Individual Selection Criteria

In addition to having one of the clinical indications above, the individual must not have a contraindication as defined by the American Society of Transplantation in Guidelines for the Referral and Management of Patients Eligible for Solid Organ Transplantation (2001) listed below.

Absolute Contraindications for Transplant Recipients include, but are not limited to, the following:

1. Metastatic cancer
2. Ongoing or recurring infections that are not effectively treated
3. Serious cardiac or other ongoing insufficiencies that create an inability to tolerate transplant surgery
4. Serious conditions that are unlikely to be improved by transplantation as life expectancy can be finitely measured
5. Demonstrated nonadherence, which places the organ at risk by not adhering to medical recommendations
6. Potential complications from immunosuppressive medications are unacceptable to the individual
7. Acquired immune deficiency syndrome (AIDS) (diagnosis based on Centers for Disease Control and Prevention (CDC) definition of CD4 count, below 200 cells/mm³) unless the following are noted:
   1. CD4 count greater than 200 cells/mm³ for greater than 6 months
   2. HIV-1 RNA undetectable
   3. On stable antiretroviral therapy greater than 3 months
   4. No other complications from AIDS (for example, opportunistic infection, including aspergillosis, tuberculosis, coccidioidomycosis, resistant fungal infections, Kaposi’s sarcoma or other neoplasm)
   5. Meeting all other criteria for small bowel or multivisceral transplantation

This document describes clinical studies and expert recommendations, and explains when small bowel, small bowel/liver transplantation, and multivisceral transplantation may be clinically appropriate. The following summary does not replace the medical necessity statement or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Intestinal failure means the small bowel cannot absorb enough food, water, or salts. It may happen when much of the bowel is missing or does not work. One possible treatment is the use of total parenteral nutrition (TPN), which gives nutrition and fluids through a vein. When TPN fails, organ transplant may be appropriate.

A small bowel (small intestine) transplant replaces the failing small bowel. A small bowel and liver transplant replaces both organs. A multivisceral, or multiple-organ, transplant replaces the bowel, liver, and other organs in the belly. In some cases a first transplant may fail, possibly leading to a repeat transplant. In some cases organ transplant may involve organs from a living donor or from a person who has passed away (deceased donor). These types of organ transplants may restore the ability of a person to receive proper nutrition and reduce some harms from long-term TPN. Transplant surgery is a major surgery and each type of transplant has drawbacks, including bleeding, blood clots, infection, rejection, organ failure, or death. Rejection means the person’s immune system attacks the new organ, leading to organ failure. To help prevent rejection, lifelong drugs are needed. However, anti-rejection drugs lower the body’s defenses against infection. A living donor also faces risk of harm such as infections and bleeding.

Description of different transplant surgeries:

• A small bowel transplant replaces the small intestine with a donor intestine. Most donor intestines come from a person who has died. In rare cases, a living donor gives part of the intestine.
• A combined small bowel and liver transplant replaces both organs.
• A multivisceral transplant replaces the small bowel and liver, plus one or more other organs in the abdomen (belly).

What the Studies Show

Results of transplant surgeries vary by age, health, and transplant type, and it can be difficult to predict what will happen to any single person. Studies show that many people who receive these types of transplants are alive several years after surgery, although outcomes vary depending on age, overall health, and the type of transplant. People receiving an intestine alone generally have better survival than those who also require a liver transplant or more complex transplant surgery.

Only one small study has evaluated intestinal transplantation for advanced pseudomyxoma peritonei, a rare cancer-related condition in which thick, jelly-like material builds up inside the abdomen. Although some people lived longer and reported better quality of life, the cancer returned or worsened in most participants. More research is needed before this treatment can be considered an accepted treatment for this condition.

When Are These Transplants Clinically Appropriate?

A transplant may be clinically appropriate when it is expected to improve health and all of the conditions below are met. The transplant team must also determine that surgery and the lifelong medicines needed after transplant are appropriate for the individual.

Small bowel transplant from a deceased donor

This transplant may be clinically appropriate when all of the following apply:

• The adult or child has short bowel syndrome or permanent intestinal failure.
• Total parenteral nutrition (TPN) is no longer a safe or effective long-term treatment because of at least one of the following:
  • Liver damage with signs of liver failure.
  • Blood clots in two or more major veins used for TPN.
  • Two or more serious bloodstream infections related to the central line within 1 year that require hospitalization.
  • A fungal bloodstream infection, septic shock, or severe lung injury caused by infection.
  • Frequent, severe dehydration despite TPN and intravenous (IV) fluids.

• The person meets the transplant center's selection requirements.

Small bowel transplant from a living donor

This transplant may be clinically appropriate when both of the following apply:

• The person meets the requirements for a deceased-donor small bowel transplant.
• A suitable deceased-donor small bowel is not available.

Combined small bowel and liver transplant from a deceased donor

This transplant may be clinically appropriate when both of the following apply:

• The person meets the requirements for a small bowel transplant.
• The person has liver failure, is expected to develop liver failure soon, or their anatomy makes a small bowel transplant alone impossible.

Multivisceral transplant from a deceased donor

This transplant may be clinically appropriate when both of the following apply:

• The person meets the requirements for a combined small bowel and liver transplant.
• One or more additional abdominal organs must also be replaced because of organ failure or the person's anatomy.

Retransplantation

Another transplant may be clinically appropriate if either of the following applies:

• The first transplant failed because of a surgical complication or very rapid rejection.
• The transplant failed because of long-term rejection or because the original disease returned, and the person still meets the transplant center's selection requirements.

Decisions about transplantation are individualized. Even when these criteria are met, the transplant team must determine whether transplantation is expected to improve the person's health and whether it can be performed safely.

When Are These Transplants Not Clinically Appropriate?

Small bowel and multivisceral transplants are not clinically appropriate for uses other than those listed above because they have not become generally accepted treatments for those conditions or have not been shown to improve health outcomes compared with established treatment.

(Return to Description/Scope)

Summary

Small bowel, combined small bowel/liver, and multivisceral transplantation are established treatment options for carefully selected adults and children with irreversible intestinal failure who can no longer be safely or effectively maintained with total parenteral nutrition (TPN). The purpose of these procedures is to restore intestinal function, improve nutritional status, and reduce the risk of life-threatening complications associated with permanent intestinal failure and long-term TPN. Evidence supporting these procedures comes primarily from transplant registry data, multicenter observational studies, and professional society recommendations, which demonstrate improving survival and functional outcomes at experienced transplant centers for appropriately selected individuals. These procedures are considered when intestinal failure persists and the classic criteria for TPN failure are met.

Isolated small bowel transplantation may be medically necessary for individuals with short bowel syndrome or irreversible intestinal failure who have failed TPN, because transplantation carries substantial operative risk and lifelong immunosuppression. Most individuals with intestinal failure can be maintained successfully with TPN for prolonged periods. Therefore, transplantation is reserved for situations in which TPN is no longer a clinically appropriate long-term treatment because it has resulted in, or is expected to result in, serious complications that threaten survival.

TPN failure is defined using well-established clinical criteria that identify individuals whose ongoing dependence on TPN is associated with unacceptable risk. These include progressive liver injury leading to impending or overt liver failure, loss of central venous access due to thrombosis of two or more major central veins, recurrent life-threatening central line infections, or severe dehydration that cannot be adequately managed despite maximal intravenous nutritional and fluid support. These complications indicate that continued TPN is no longer an effective or clinically appropriate long-term treatment and that intestinal transplantation may provide greater overall clinical benefit.

Living-donor small bowel transplantation remains uncommon. Available registry analyses suggest that outcomes are comparable to those of deceased-donor transplantation after adjustment for baseline differences. However, living donation exposes a healthy donor to major surgery without direct medical benefit. For that reason, the policy limits living-donor transplantation to situations in which an appropriate deceased-donor intestine is not available for an individual who already meets criteria for transplantation. This approach preserves deceased-donor transplantation as the preferred treatment while allowing living donation when necessary to avoid potentially life-threatening delays.

Combined small bowel/liver transplantation is reserved for individuals who meet criteria for intestinal transplantation and also have irreversible liver failure or anatomical abnormalities that prevent successful isolated intestinal transplantation. Liver failure most commonly develops as a consequence of long-term TPN-associated liver disease. Replacing only the intestine would not correct the coexisting liver failure, making combined transplantation clinically appropriate in this setting.

Multivisceral transplantation is limited to individuals who meet criteria for combined small bowel/liver transplantation and who also require transplantation of one or more additional abdominal organs because of concomitant organ failure or anatomical abnormalities. These extensive procedures are appropriate only when replacement of multiple organs is necessary to restore gastrointestinal function and cannot be accomplished through isolated intestinal or combined small bowel/liver transplantation.

Retransplantation is considered medically necessary when graft failure occurs because of technical failure, hyperacute rejection, chronic rejection, or recurrent disease and the individual continues to satisfy transplant selection criteria. In these situations, retransplantation may again provide meaningful clinical benefit because the underlying indication for transplantation remains present and the individual remains an appropriate transplant candidate.

Individuals considered for small bowel transplantation must also meet general transplant selection criteria based on longstanding recommendations from the American Society of Transplantation. These criteria recognize that transplantation is appropriate only when the individual is likely to tolerate surgery, benefit from transplantation, and successfully participate in the lifelong medical care required after transplant. Absolute contraindications include conditions such as uncontrolled infection, metastatic malignancy, severe comorbid illness that precludes surgery, inability to safely receive immunosuppressive therapy, or demonstrated inability to adhere to the complex post-transplant treatment plan. These conditions substantially reduce the likelihood that transplantation will improve health outcomes.

Small bowel transplantation is not medically necessary for individuals who can continue to tolerate TPN because TPN remains an established and clinically appropriate treatment for maintaining nutrition in these individuals. Likewise, living-donor small bowel transplantation is not medically necessary when a deceased-donor intestine is available because deceased-donor transplantation avoids exposing a healthy donor to unnecessary operative risk while providing comparable recipient outcomes.

All other indications for small bowel or multivisceral transplantation, including treatment of pseudomyxoma peritonei, are considered investigational and not medically necessary. Although isolated reports demonstrate that transplantation is technically feasible in selected individuals with advanced pseudomyxoma peritonei, the available evidence consists of a single uncontrolled case series with a very small number of participants and a high rate of tumor recurrence. No professional society guideline recommends intestinal or multivisceral transplantation as an accepted treatment for this condition, and the available evidence has not established that transplantation is in accordance with generally accepted standards of medical practice or that it provides a net clinical benefit compared with established management. Similarly, evidence supporting living-donor multivisceral transplantation remains extremely limited, and the procedure has not been established as a generally accepted treatment. Accordingly, these indications remain investigational and not medically necessary.

Discussion

Intestinal Failure and Indications for Transplantation

Intestinal failure is a malabsorptive state in which the gastrointestinal tract cannot maintain nutrition, fluid, and electrolyte balance. The most common cause is extensive resection for short bowel syndrome, which itself can be due to volvulus, atresias, necrotizing enterocolitis, Crohn disease, gastroschisis, superior mesenteric artery thrombosis, desmoid tumors, or trauma. Motility disorders and malabsorptive or secretory disorders can also lead to intestinal failure. Individuals who cannot maintain their nutritional status orally or via enteral feeding may require TPN. Long-term TPN may fail or cause life-threatening complications that prompt consideration of intestinal transplantation (Bhamidimarri, 2014; Mangus, 2013).

A 2019 international consensus updated the indications for intestinal transplantation in permanent intestinal failure (Kaufman, 2020). The principal transplant triggers it identified are intestinal failure-associated liver disease, progressive loss of central venous access, and repeated life-threatening central venous catheter-associated infections requiring critical care (Kaufman, 2020). It also recognized additional indications, including large desmoid tumors, extensive mesenteric vein thrombosis with intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea (Kaufman, 2020). Improvements in intestinal rehabilitation and parenteral nutrition reduced worldwide transplant volume from a peak of 270 procedures per year in 2008 to 149 per year in 2017, while recipient survival at 1 year now exceeds 90% at experienced centers (Kaufman, 2020; Fishbein, 2009).

Transplant Approaches and Donor Considerations

Most intestinal transplants use deceased donors. Living donation is rare. Theoretical advantages include elective timing, improved matching, and shorter ischemia times, but early experience was limited to case reports and small series (Benedetti, 2006; Gangemi, 2009; Ji, 2009; Li, 2008; Smith, 2016; Tzvetanov, 2010). Contemporary registry analysis shows living-donor outcomes comparable to deceased-donor outcomes when matched. In a propensity-matched cohort from the International Intestinal Transplant Registry, 1-year survival was 74.3% for living donor transplants compared to 80.3% for cadaveric transplants. The 5-year survival was 49.8% compared to 48.1%; acute rejection rates were similar (Ceulemans, 2023).

Combined small bowel and liver transplantation is appropriate for individuals who meet criteria for intestinal transplantation and have irreversible liver disease. This pattern is more common in pediatrics (Middleton, 2005; Vianna, 2008). Multivisceral transplantation is reserved for concomitant organ failure or anatomy that precludes isolated grafts and remains complex, with improving but nontrivial mortality and late morbidity. Experience from single centers and national data support continued use in carefully selected cases (Grant, 2005; Grant, 2015; Mangus, 2013). National outcomes for primary intestinal transplantation in the United States from 2008-2015 show that outcomes vary by age and whether the liver is included. Among 2017-2019 adult recipients, 1- and 5-year individual survival was 91.0% and 69.0% for intestine-without-liver transplantation and 57.1% and 46.8% for intestine-with-liver transplantation. Among pediatric recipients, corresponding survival was 88.6% and 77.1% without liver and 84.0% and 65.4% with liver (Horslen, 2026). Pediatric registry analyses show similar patterns, with chronic rejection the predominant cause of late graft loss. Inclusion of the liver is associated with lower chronic rejection in some series (Hind, 2021; Raghu, 2019).

Candidate Selection and Clinical Outcomes

Recipient functional status also provided important prognostic information during pretransplant evaluation. In a retrospective cohort of 1,254 US adults who underwent first-time intestinal transplantation, recipients with severe pretransplant functional impairment (Karnofsky Performance Status 10% - 40%) had a 56% higher risk of death at 1 year and a 58% higher risk at 5 years than recipients with normal functional status (Karnofsky Performance Status 80% - 100%) (Boateng, 2024). Recipients whose functional status failed to improve or declined after transplantation also experienced poorer survival.

A prospective multicenter cohort of Japanese children with intestinal failure similarly found that 6 of 14 children (44%) with a performance status of 3 or worse at enrollment had died or remained severely impaired at 3 years, suggesting that functional status carries prognostic value in children as well (Ueno, 2018).

Successful intestinal transplantation is generally associated with improved quality of life, and this improvement may support the decision to proceed when established medical indications for transplantation are present. However, because intestinal transplantation requires lifelong immunosuppression with associated risks, an expectation of improved quality of life alone is not considered sufficient justification for transplantation (Kaufman, 2020).

Long-term follow-up of pediatric intestinal transplant survivors suggests that successful transplantation can support sustained linear growth, although some children require prolonged nutritional support. In a retrospective single-center cohort of 133 children who survived at least 5 years after intestinal transplantation and were followed for up to 15 years, height z-scores increased significantly over the follow-up period, while body mass index z-scores trended downward. Children who underwent isolated intestinal transplantation had higher height z-scores than multivisceral recipients (Miri, 2025). Children with partial gastrectomy, a permanent ostomy, or developmental delay were more likely to require supplemental tube feeding for as long as 15 years after transplantation (Miri, 2025).

Retransplantation

Retransplantation may be considered after intestinal graft failure when the individual continues to meet transplant selection criteria. Successful retransplantation requires reassessment of functional status, comorbidities, prior sensitization, and donor-specific antibodies, with careful selection of graft type and perioperative management. Contemporary series indicate improving patient and graft survival in well-selected recipients, with outcomes attributed to advances in immunosuppression, surgical techniques, and infection monitoring rather than broader eligibility for retransplantation (Ganoza, 2018).

In a national Organ Procurement and Transplantation Network (OPTN) analysis, adult recipients undergoing isolated intestinal retransplantation had patient survival of 80.1%, 47.4%, and 28.5% at 1, 3, and 5 years, significantly lower than after primary isolated transplantation. In contrast, survival after adult liver-inclusive intestinal retransplantation (63.1%, 56.1%, and 46.8% at 1, 3, and 5 years) did not differ significantly from primary liver-intestine transplantation, suggesting that retransplantation may remain an appropriate option for carefully selected individuals requiring combined liver-intestine replacement. In multivariable analysis, hospitalization immediately before retransplantation was the only independent predictor of poorer survival (hazard ratio [HR], 5.4; 95% confidence interval [CI], 1.9-15.6), indicating that retransplantation performed before clinical deterioration requiring hospitalization may improve outcomes (Desai, 2012). Reported outcomes are more favorable for liver-inclusive grafts than for repeat isolated intestinal grafts, supporting retransplantation as an appropriate option when the underlying indication persists (Ganoza, 2018; Desai, 2012).

Special and Investigational Indications

Chronic intestinal pseudo-obstruction (CIPO) is defined by recurrent or continuous symptoms of intestinal obstruction (such as abdominal distention, pain, nausea, vomiting, and constipation) in the absence of a mechanical cause, due to impaired neuromuscular function of the gut wall. It can affect the small intestine, colon, or both, and may also involve other parts of the gastrointestinal tract. Single-center data suggest reasonable mid-term survival and graft outcomes after intestinal or multivisceral transplantation in selected adults with CIPO, with lower survival in children (Sogawa, 2021).

For neuroendocrine tumors extending beyond the liver, evidence remains limited to small retrospective series with heterogeneous populations and variable oncologic control, and transplantation is not established care (Duchateau, 2022).

Pseudomyxoma peritonei (PMP) is a rare condition characterized by the accumulation of mucinous (gel-like) material within the peritoneal cavity, usually resulting from a mucin-producing epithelial tumor. The label is imprecise because PMP can refer to both low-grade and high-grade disease. Standard therapy for PMP is cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Extensive small bowel serosal involvement is often an absolute contraindication to CRS and HIPEC. No verified guideline endorses intestinal or multivisceral transplantation as standard therapy for PMP, and there is no consensus therapy in that setting (Gaertner, 2025; Godfrey, 2026; Govaerts, 2021; National Comprehensive Cancer Network [NCCN] Appendiceal Neoplasms and Cancers V.4 2026). Reddy and colleagues reported outcomes for 15 consecutive individuals treated with intestinal or modified multivisceral transplantation for advanced, nonresectable PMP with nutritional failure when no conventional operative solution remained. Selection criteria for this single-center study required a high peritoneal cancer index with small bowel involvement, low-grade disease or slowly progressive high-grade disease, and TPN requirement or imminent TPN. Participants underwent tailored grafting, including isolated intestine or modified multivisceral grafts, with abdominal wall transplantation when needed. One-year and actuarial 5-year survival rates were 79% and 55%. Death-censored graft survival was 77% and 56%, and 72% of evaluable survivors were free from home TPN at 1 year. Quality of life (QOL) improved, with higher EQ-5D-5L index values and visual analog scores and reductions in pain and limitations in usual activities. Tumor progression or recurrence occurred in 91% of individuals with at least 6 months of follow-up. Operative intensity was high, with long procedures, substantial transfusion requirements, and prolonged hospitalizations, and early and late transplant complications occurred. This pioneering but preliminary case series showed that intestinal or multivisceral transplantation can extend survival and improve QOL in some individuals with terminal PMP not amenable to CRS/HIPEC. However, the study’s limited size, absence of controls, and very high recurrence rate mean the findings should be interpreted as hypothesis-generating rather than practice-changing (Reddy, 2023).

Possible types of transplants that include the small bowel are isolated small bowel, combined small bowel/liver, and multivisceral transplant. The type of transplant is chosen on a case-by-case basis depending on anatomy and disease process (Kubal, 2015). The most common of these procedures is the isolated small bowel (intestinal) transplantation (Beyer-Berjot, 2012). An isolated small bowel transplant usually involves the removal of the small intestine from a deceased donor, removal of the recipient’s small intestine, and replacement with the donor’s intestine. If a living donor is used, a segment of the donor’s small intestine is transplanted. A small bowel transplant is intended to restore adequate nutrition in individuals with short bowel syndrome. This is a condition in which the absorbing surface of the small intestine is nonfunctional due to extensive disease or surgical removal of a large portion of the small intestine.

Evidence of intolerance or failure of total parenteral nutrition (TPN) includes, but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications or the development of progressive but reversible liver failure. In the event of progressive liver failure, small bowel transplantation may be considered to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant.

A small bowel/liver transplant involves the transplantation of a cadaveric small intestine and liver into a recipient. Small bowel/liver transplants are typically performed for individuals with short bowel syndrome and concurrent liver failure or anatomical abnormalities.

A multivisceral transplant typically includes the small bowel/liver, in combination with one or more other abdominal visceral organs such as the stomach, pancreas or colon which may be transplanted due to concomitant organ failure or anatomical abnormalities. The most common indications for multivisceral transplantation are total occlusion of the splanchnic circulation, extensive gastrointestinal polyposis, hollow visceral myopathy or neuropathy, and some abdominal malignancies.

Cadaver: The physical remains of a deceased person.

Short bowel syndrome: A malabsorption syndrome resulting from a significantly reduced small intestine.

Total parenteral nutrition (TPN): A method of supplying nourishment to children and adults who are unable to eat.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

Associated Coding

When services may also be Medically Necessary for associated, secondary services when criteria are met for the primary transplantation procedure codes listed above:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met for small bowel transplants; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other indications including but not limited to the following diagnosis code; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Benedetti E, Holterman M, Asolati M, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg. 2006; 244(5):694-699.
2. Beyer-Berjot L, Joly F, Dokmak S, et al. Intestinal transplantation: indications and prospects. J Visc Surg. 2012; 149(6):380-384.
3. Bhamidimarri KR, Beduschi T, Vianna R. Multivisceral transplantation: where do we stand? Clin Liver Dis. 2014; 18(3):661-674.
4. Ceulemans LJ, Dubois A, Clarysse M, et al. Outcome after intestinal transplantation from living versus deceased donors: a propensity-matched cohort analysis of the International Intestinal Transplant Registry. Ann Surg. 2023; 278(5):807-814.
5. Desai CS, Khan KM, Gruessner AC, et al. Intestinal retransplantation: analysis of Organ Procurement and Transplantation Network database. Transplantation. 2012; 93(1):120-125.
6. Duchateau NM, Canovai E, Vianna RM, et al. Combined liver-intestinal and multivisceral transplantation for neuroendocrine tumors extending beyond the liver: a systematic literature review. Transplant Rev (Orlando). 2022; 36(1):100678.
7. Fishbein TM. Intestinal transplantation. N Engl J Med. 2009; 361(10):998-1008.
8. Gangemi A, Tzvetanov IG, Beatty E, et al. Lessons learned in pediatric small bowel and liver transplantation from living-related donors. Transplantation. 2009; 87(7):1027-1030.
9. Ganoza A, Celik N, Mazariegos GV. Intestinal re-transplantation: indications, techniques and outcomes. Curr Opin Organ Transplant. 2018; 23(2):224-228.
10. Govaerts K, Lurvink RJ, De Hingh IHJT, et al. Appendiceal tumours and pseudomyxoma peritonei: literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment. Eur J Surg Oncol. 2021; 47(1):11-35.
11. Grant D, Abu-Elmagd K, Mazariegos G, et al.; Intestinal Transplant Association. Intestinal transplant registry report: global activity and trends. Am J Transplant. 2015; 15(1):210-219.
12. Grant D, Abu-Elmagd K, Reyes J, et al. Intestine Transplant Registry. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. 2005; 241(4):607-613.
13. Hind JM. Long-term outcomes of intestinal transplantation. Curr Opin Organ Transplant. 2021; 26(2):192-199.
14. Ji G, Chu D, Wang W, Dong G. The safety of donor in living donor small bowel transplantation—an analysis of four cases. Clin Transplant. 2009; 23(5):761-764.
15. Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep. 2015; 17(1):5.
16. Li M, Ji G, Feng F, et al. Living-related small bowel transplantation for three patients with short gut syndrome. Transplant Proc. 2008; 40(10):3629-3633.
17. Mangus RS, Tector AJ, Kubal CA, et al. Multivisceral transplantation: expanding indications and improving outcomes. J Gastrointest Surg. 2013; 17(1):179-186.
18. Middleton SJ, Jamieson NV. The current status of small bowel transplantation in the UK and internationally. Gut. 2005; 54(11):1650-1657.
19. Raghu VK, Beaumont JL, Everly MJ, et al. Pediatric intestinal transplantation: analysis of the intestinal transplant registry. Pediatr Transplant. 2019; 23(8):e13580.
20. Reddy S, Punjala SR, Allan P, et al. First report with medium-term follow-up of intestinal transplantation for advanced and recurrent nonresectable pseudomyxoma peritonei. Ann Surg. 2023; 277(5):835-840.
21. Smith JM, Skeans MA, Horslen SP, et al. Intestine. Am J Transplant. 2016; 16(Suppl 2):99-114.
22. Sogawa H, Costa G, Armanyous S, et al. Twenty years of gut transplantation for chronic intestinal pseudo-obstruction: technical innovation, long-term outcome, quality of life, and disease recurrence. Ann Surg. 2021; 273(2):325-333.
23. Tzvetanov IG, Oberholzer J, Benedetti E. Current status of living donor small bowel transplantation. Curr Opin Organ Transplant. 2010; 15(3):346-348.
24. Ueno T, Wada M, Hoshino K, et al. Three-year prospective follow-up of potential pediatric candidate for intestinal transplantation. Transplant Proc. 2018; 50:2779-2782.
25. Vianna RM, Mangus RS, Tector AJ. Current status of small bowel and multivisceral transplantation. Adv Surg. 2008; 42:129-150.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology. 2003; 124(4):1105-1110.
2. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Intestinal and Multi-Visceral Transplantation (260.5). Version 2. Effective May 11, 2006. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=280. Accessed on August 14, 2026.
3. Gaertner WB, Brown SR, Deutsch M, et al.; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. Management of appendiceal neoplasms (2025). Dis Colon Rectum. 2025; 68:815-834.
4. Godfrey EL, Mahoney F, Bansal VV, et al.; Peritoneal Surface Malignancies Consortium Group. Consensus guideline for the management of patients with appendiceal tumors, part 2: appendiceal tumors with peritoneal involvement. Ann Surg Oncol. 2026; 33(6):5176-5203.
5. Horslen SP, Raghu VK, Schladt DP, et al. OPTN/SRTR 2024 Annual Data Report: Intestine. HHS/HRSA; 2026. Available at: https://srtr.hrsa.gov/adr/2024/Intestine/. Accessed on August 14, 2026.
6. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant. 2001; 5(2):80-87.
7. Kaufman SS, Avitzur Y, Beath SV, et al. New insights into the indications for intestinal transplantation: consensus in the year 2019. Transplantation. 2020; 104(5):937-946.
8. NCCN Clinical Practice Guidelines in Oncology. © 2026. National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on August 14, 2026.
   • Appendiceal Neoplasms and Cancers (V.4 2026)
9. Pironi L, Cuerda C, Jeppesen PB, et al. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr. 2023; 42(10):1940-2021.

1. Scientific Registry of Transplant Recipients. Available at: https://srtr.hrsa.gov/. Accessed on August 14, 2026.
2. United Network for Organ Sharing (UNOS). Available at: http://www.unos.org. Accessed on August 14, 2026.

Intestinal Transplant
Small Bowel Transplant
Small Bowel/Liver Transplant
Multivisceral Transplant
Total Parenteral Nutrition
TPN

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only – American Medical Association