Intestinal Transplantation (CPB 0605, reviewed 2026-09-03)
Aetna's Intestinal Transplantation policy (CPB 0605) treats intestinal transplant as medically necessary for persons with clinical indicators of failed total parenteral nutrition (TPN), such as frequent severe dehydration despite IV fluids, 2 or more hospitalized episodes of line-infection sepsis per year, impending or overt liver failure, or thrombosis or loss of central venous access, when the selection criteria are met. Combined intestinal and liver transplant is medically necessary for advanced liver disease that requires liver transplantation when the same criteria are met, except for the liver function requirement, and multi-visceral transplants from deceased donors are medically necessary for adults and children who meet the combined small bowel/liver criteria and need one or more additional abdominal organs. Fecal calprotectin testing for intestinal allograft rejection and intestinal transplant for recurrent non-resectable pseudomyxoma peritonei are listed as experimental, investigational or unproven, and the policy was last reviewed 09/03/2026.