A small bowel transplant using cadaveric intestine may be considered medically necessary in adult and pediatric individuals 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 dependence on total parenteral nutrition (TPN) and are developing or have developed severe complications due to TPN.
A small bowel transplant using a living donor may be considered medically necessary only when a cadaveric intestine is not available for transplantation in an individual who meets the criteria noted above for a cadaveric intestinal transplant.
A small bowel retransplant may be considered medically necessary after a failed primary small bowel transplant.
A small bowel transplant using living donors is considered not medically necessary in all other situations.
A small bowel transplant is considered investigational for adult and pediatric individuals with intestinal failure who can tolerate TPN.
