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AetnaCommercial · Coverage · Medical Policy · Transplant Surgery, Gastroenterology, General SurgeryMedium impact

Intestinal Transplantation (CPB 0605, reviewed 2026-09-03)

Effective date
Not stated in the notice
Identified
Oct 6, 2026

Summary

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.

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What to do

Action · 5 steps
01Before billing intestinal transplant codes CPT 44132, 44133, 44135, 44136, 44137, 44715, 44720 or 44721, or HCPCS S2053, S2054 or S2055, confirm the patient meets the transplanting institution's protocol eligibility criteria.
02Without a protocol, all of these selection criteria must be met: no acute or chronic active infection that is not effectively treated; ejection fraction of at least 40%; bilirubin under 2.5 mg/dL and creatinine clearance above 50 mL/min/kg; no uncontrolled or untreated psychiatric disorder that interferes with a strict treatment regimen; and, for HIV/AIDS, a CD4 count above 200 cells/mm3 for more than 6 months, undetectable HIV-1 RNA, no other AIDS complications such as opportunistic infections or neoplasms, and stable antiviral therapy for more than 3 months.
03For a combined intestinal and liver transplant, renal function must be assessed with a measured glomerular filtration rate, because a calculated GFR is inaccurate in advanced liver disease.
04Intestinal transplant is considered not medically necessary for the listed contraindications, including unstable psychiatric disease, active substance abuse, and homelessness, unless the substance use exception applies: supporting documentation within 4 weeks showing 3 months of stability from a treating addiction medical professional or psychiatrist.
05Fecal calprotectin (CPT 83993) is not covered as a test for intestinal allograft rejection.

Codes mentioned

441324413344135441364413744715447204472183993S2053S2054S2055K91.2Z90.49

Original notice

Intestinal Transplantation (CPB 0605, reviewed 2026-09-03)
aetna.com · Always check the source before changing claims.
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Related changes

See all Aetna changes →
Intestinal Transplantation (CPB 0605, reviewed 2025-09-10)MediumNo effective date · Medical PolicyHeart-Lung Transplantation (CPB 0597, reviewed 2026-09-08)MediumNo effective date · Medical PolicyHeart-Lung Transplantation (CPB 0597, reviewed 2025-12-02)MediumNo effective date · Medical PolicyIntestinal Rehabilitation Programs (CPB 0342, reviewed 2026-05-21)MediumNo effective date · Medical PolicyBrowse every Aetna change in the policy list

Related policy hubs

Aetna policiesTransplant SurgeryGastroenterologyGeneral SurgeryCode 44132Code 44133Code 44135Code 44136Code 44137Code 44715Code 44720Code 44721Code 83993Code S2053Code S2054Code S2055Code K91.2Code Z90.49

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