Medicare Coverage of Intestinal Transplantation

Surgeons at the University of Pittsburgh Medical Center (UPMC) have pioneered the relatively new technology of intestinal transplantation. During the 1990s, the center performed 160 transplants in 150 patients with irreversible intestinal failure due to disease, injury, or abnormalities at birth.

While intestinal transplantation is still not a commonly performed procedure, recent advances have given rise to greatly improved survival rates. At UPMC, actuarial patient survival at one and five years was 72% and 48%, respectively by the late ’90s. Such results are similar to those achieved with lung transplantation, a procedure the United States Health Care Finance Administration (HCFA) recognizes as reimbursable under its Medicare program.

Kareem Abu-Elmagd, Director of Intestinal Rehabilitation and Transplantation at UPMC's Thomas E. Starzl Transplantation Institute, felt that these encouraging gains justified a new perception of this procedure. In February of 1999, Dr. Abu-Elmagd formally requested that HCFA change its policy to approve Medicare coverage of intestinal transplantation.

Dr. Abu-Elmagd's appeal resulted in the procedure’s approval by the federal Medicare program on October 4th, 2000. This means that intestinal transplantation is now subject to a national coverage policy, making it available to more patients. Because many people who need transplants are on disability, Medicare covers them even if they are younger than 65. Additionally, private health insurers and state Medicaid programs generally follow Medicare's lead.

In its deliberation on the request, HCFA relied on a variety of sources:

• Dr. Abu-Elmagd submitted information that included 11 distinct studies. As one of the most published researchers on the topic of intestinal transplantation, Dr. Abu-Elmagd had been involved in many of the studies.
• A Blue Cross Blue Shield Technology Evaluation Center assessment reviewed the technology behind intestinal transplantation, using a standard set of criteria.
• The Center for Practice and Technology Assessment at the Agency for Healthcare Research and Quality (AHRQ) also performed an assessment of intestinal transplantation. They performed a computerized literature search, supplementing this with a review of the sources listed above.
• HCFA posted a series of questions on its Internet site, in order to solicit information that would assist it in developing an appropriate policy.

The Total Parenteral Nutrition Restriction

Based on the data it obtained, HCFA determined that bowel and related transplantation represent potentially life-saving options for patients whose other treatments have failed. An important treatment for intestinal failure is total parenteral nutrition (TPN), in which the patient is nourished intravenously. Many adults and children are able to maintain their health on TPN for long periods, but sometimes long-term TPN leads to life-threatening complications such as liver failure. In its decision memorandum, HCFA stated that it lacked sufficient data “to determine whether the risks and benefits of small bowel transplant and related procedures might yield a net benefit to patients who can continue TPN, but are considered at high risk to fail TPN sometime in the future.” Consequently, HCFA specified that intestinal transplants should be subject to certain restrictions under Medicare. To date, Medicare coverage of the procedure is limited to patients who have failed TPN, or have developed life-threatening complications while on TPN.

Additionally, due to the risk associated with intestinal transplantation, coverage is similarly restricted to “carefully selected centers with demonstrated success.” Qualified transplant centers perform at least 10 intestinal transplants per year, with a one-year actuarial survival of 65 percent. Only a few medical centers in the United States meet Medicare's requirements, including the University of Pittsburgh.

Learn more about Intestinal Transplant Safety and Best Practices.