23 Miss. Code. R. 202-4.18

Current through December 10, 2024

Rule 23-202-4.18 - Small Bowel Transplant

A. Prior authorization is required.

B. Medicaid covers small bowel transplants meeting the following criteria for small bowel (or intestinal) transplantation, whether performed as a solitary procedure (SBT); or performed in conjunction with liver (SB/LT); or with stomach, duodenum, and pancreas, with or without liver (SB/MVT) transplantation:

1. The loss or absence of sufficient absorptive capacity of the intestinal tract to support life; and

2. The demonstrated failure of total parenteral nutrition (TPN).

C. Concomitant liver or multivisceral transplantation can only be medically justified by documentation of severe and irreversible damage to the individual organ(s) to be replaced. Concomitant live or multivisceral transplants must meet the following criteria:

1. Candidate is less than sixty-five (65) years of age.

2. Meets transplanting facility blood and tissue-type compatibility standards.

3. Infections controlled for at least forty-eight (48) hours prior to transplant

4. Absence of severe and irreversible end organ dysfunction, to include cardiac, central nervous system, pulmonary, renal, peripheral vascular or cerebrovascular.

5. All other treatments have been attempted or considered and none will prevent progressive disability and/or death.

6. The candidate and/or legal representative understands the transplant risks and benefits, gives informed consent, and has the capacity and is willing to comply with needed care, including immunosuppressive therapy.

7. The candidate has been approved by the transplant review team.

8. Required serology studies have been completed for HIV, Hepatitis A, B, and C, Cytomegalovirus (CMV), and Varicella.

9. Immunizations have been administered as follows:

a) All immunizations for children age two (2) to six (6) are up-to-date in accordance with the most current recommended childhood immunization schedule developed and endorsed by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

b) Hepatitis A, if serology does not indicate immunity.

c) Hepatitis B, if serology does not indicate immunity.

d) Pneumococcal.

e) Influenza, annually.

10. A psychosocial evaluation has been performed for the adult candidate or, if the candidate is a child, for the family, with the following results:

a) Candidate's psychiatric disorders, if present, are being treated.

b) Candidate's social support system has been evaluated and found to be adequate.

c) Candidate has no previous history of significant non-compliance to medical treatment.

11. Specific Diagnostic Inclusion Criteria

a) Severe and irreversible intestinal insufficiency, congenital or acquired, including, but not limited to the following causes:

1) Intestinal atresia.

2) Splanchnic vascular occlusive disease.

3) Gastroschisis.

4) Inflammatory bowel disease.

5) Microvillus involution disease, intractable diarrhea of infancy.

6) Post-traumatic, including surgical short bowel syndrome.

7) Volvulus.

8) Necrotizing enterocolitis.

9) Chronic intestinal pseudo-obstruction.

10) Radiation enteritis.

b) Failure of Total Parenteral Nutrition (TPN) as documented by:

1) Overt or impending liver failure due to TPN-induced hepatic injury,

2) Thrombosis of two or more central venous channels: jugular, subclavian, femoral,

3) Two or more episodes of TPN catheter-induced sepsis in a year or a single episode of line-related fungemia, or

4) Frequent episodes of dehydration due to uncontrollable and high volume loss of fluids through the gastrointestinal tract.

12. Facility is approved for small bowel transplants by Medicaid.

D. Small bowel transplants are not covered when the candidate has one (1) of the following:

1. Active chemical dependency, drugs or alcohol within the preceding six (6) months.

2. Profound and progressive neurological dysfunction, like Tay-Sachs.

3. Non-correctable non-gastrointestinal disease with a lethal prognosis.

4. Congenital immunodeficiency syndrome.

5. Active tuberculosis or active sepsis.

6. Uncorrectable absence of an essential psychosocial support system.

7. Unmanageable psychiatric disorder felt to significantly compromise compliance with the post-transplant regimen.

8. HIV.

9. Systemic malignancy.

23 Miss. Code. R. 202-4.18

Miss. Code Ann. § 43-13-121; 42 CFR 482.90104.