Liver Transplant*

Medical Policy: 07.03.03 
Original Effective Date: November 2009 
Reviewed: March 2012 
Revised:  

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Liver transplantation is routinely performed as a treatment of last resort for patients with end-stage liver disease. Patients are prioritized for transplant according to length of time on the waiting list and severity of illness criteria developed by the United Network of Organ Sharing (UNOS).

Patients assigned to Status 1 are those with acute liver failure who have a life expectancy of less than 7 days. Outside of status 1, continuous numerical scales are used. The Model for End Stage Liver Disease (MELD) and Pediatric End Stage Liver Disease (PELD) are numerical scales that are currently used for liver allocation. The MELD and PELD scores have been found to be highly predictive of a patient’s risk of dying while waiting for a liver transplant, and are based on objective and verifiable medical data. Status 1 patients receive first priority when a donor liver becomes available, followed by patients with the highest MELD/PELD scores. Those with the highest scores will always be considered before those with lower scores, even if some patients with lower scores have been waiting longer.

Top

Prior Approval: 

Prior approval is recommended. Submit a prior approval now.

Top

Policy: 

A liver transplant, using a cadaver or living donor, may be considered medically necessary for patients with end-stage liver failure die to irreversibly damaged livers.

Etiologies of end-stage lever disease include, but are not limited to, the following:

• Hepatocellular diseases
  • Alcoholic cirrhosis
  • Viral hepatitis (either A, B, C, or non-A, non-B)
  • Autoimmune hepatitis
  • Alpha-1 antitrypsin deficiency
  • Hemochromatosis
  • Protoporphyria
  • Wilson disease
  • Non-alcoholic steatohepatitis (NASH)/Non-alcoholic fatty liver disease (NAFLD) 
• Cholestatic liver diseases
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis with development of secondary biliary cirrhosis
  • Biliary atresia 
• Primary hepatocellular carcinoma meeting ONE the following criteria:
  • Single lesions ≤ 5 cm
  • 2 or 3 lesions ≤ 3 cm each AND
  • No macrovascular involvement
  • No extrahepatic disease
• Intrahepatic cholangiocarcinoma when ALL of the following criteria are met:
  • Diagnosis is confirmed histologically
  • Tumor is considered unresectable
  • Absence of contraindications to neoadjuvant therapy (i.e., chemoradiation)
  • Absence of regional lymph node metastasis Note: the use of liver transplantationfor the treatment of cholangiocarcinoma should be reserved for highly selected patients in specialized centers. 
• Trauma and toxic reactions
• Budd-Chiari syndrome
• Inborn errors of metabolism
• Polycystic disease of the liver Note: these patients do not develop liver failure but may require transplant due to the anatomic complications of a grossly enlarged liver.
• Familial amyloid polyneuropathy Note: these patients do not experience liver disease, per se, but develop polyneuropathy and cardiac amyloidosis due to the production of a variant transthyretin molecule by the liver. The MELD/PELD score may apply to these patients. Candidacy for liver transplant is based on the morbidity of the polyneuropathy. Many patients may not be a candidate for transplant due to coexisting cardiac disease.

Except as defined above, candidates for all liver transplants should meet the following general criteria:

• Adequate cardiopulmonary status
• Absence of active infection
• Documentation of patient compliance with medical management

There is minimal data regarding long-term outcomes of liver transplantation in HIV-positive patients. The United Network for Organ Sharing (UNOS) believes that asymptomatic HIV-positive patients should not necessarily be excluded for candidacy for organ transplantation, stating, “A potential candidate for organ transplantation whose test for HIV is positive but who is in an asymptomatic state should not necessarily be excluded from candidacy for organ transplantation, but should be advised that he or she may be at increased risk of morbidity and mortality because of immunosuppressive therapy.” In 2001, the Clinical Practice Committee of the American Society of Transplantation proposed that the presence of AIDS could be considered a contraindication to kidney transplant unless the following criteria were present. These criteria may be extrapolated to other potential organ transplants:

• CD4 count ≥ 200 cells/mm-3 for > 6 months
• HIV-1 RNA undetectable
• On stable anti-retroviral therapy > 3 months
• No other complications from AIDS (e.g., opportunistic infection including aspergillus, tuberculosis, coccidioses mycosis, resistant fungal infections, Kaposi’s sarcoma, or other neoplasm)
• Meeting all other criteria for organ transplantation

The evaluation of a transplant candidate who has a history of cancer must consider the prognosis and risk of recurrence from available information including tumor type and stage, response to therapy, and time since therapy was completed. Although evidence is limited, patients in whom cancer is thought to be cured should not be excluded from consideration for transplant. UNOS has not addressed malignancy in current policies.

It is likely that each individual transplant center will have explicit patient selection criteria for HIV-positive patients.

Liver transplant, using a cadaver or living donor, is considered investigational for any indication not listed above including, but not limited to, the following:

• Extrahepatic malignancy including cholangiocarcinoma (except as described above)
• Hepatocellular carcinoma that has extended beyond the liver
• Patients with an active infection
• Patients with ongoing alcohol and/or drug abuse who fail to meet the abstinence criteria of the transplanting institution. (Evidence of abstinence varies among institutions, but generally a minimum of 3 months is required.)

Top

Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• 47133; Donor hepatectomy (including cold preservation), from cadaver donor
• 47135; Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age
• 47136; Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age
• 47140; Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III)
• 47141; Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III and IV)
• 47142; Donor hepatectomy (including cold preservation), from living donor; total right lobectomy (segments V, VI, VII and VIII)
• 47143; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split
• 47144; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (i.e., left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII])
• 47145; Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (i.e., left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII])
• 47146; Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each
• 47147; Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each

Top

Selected References: 

• Mazzaferro V, Regalia E, Doci R et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996; 334(11):693-700.
• Ahmed A, Keefe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis. 2007 May; 11(2):227-47.
• Ioannou GN, Perkins JD, Carithers RL Jr. Liver transplantation for hepatocellular carcinoma: Impact of the MELD allocation system and predictors of survival. Gastroenterology 2008; 134(5): 1342-51.
• Yao FY. Selection criteria for liver transplantation in patients with hepatocellular carcinoma: beyond tumor size and number? Liver Transpl. 2006 Aug; 12(8):1189-91.
• Ulrich F, Pratschke J, Neumann U et al. Eighteen years of liver transplantation experience in patients with Budd-Chiari syndrome. Liver Transpl. 2008 Feb; 14(2):144-50.
• Chan EY, Larsom AM, Fix OR et al. Identifying risk for recurrent hepatocellular carcinoma: Implications for surveillance studies and new adjuvant therapies. Liver Transpl. 2008’ 14(7): 956-65.
• United Network for Organ Sharing (UNOS). MELD?PELD Calculator Documentation. Available at: http://www.unos.org/docs/MELD_PELD_Calculator_Documentation.pdf. Accessed April 1, 2011.
• Steinman TI, Becker BN, Frost AE et al. Clinical Practice Committee, American Society of Transplantation. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001 May 15; 71(9):1189-204.
• Murad A, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009. World J Gastroenterol 2009 Sept 14; 15(34):4240-62.
• Heimbach JK, Haddock MG, Alberts SR et al. Transplantation for Hilar Cholangiocarcinoma. Liver Transpl 2004; 10:S65-S68.
• Schwartz JJ, Hutson WR, Gayowski TJ et al. Liver transplantation for cholangiocarcinoma. Transplantation. 2009 Aug 15; 88(3):295-8.
• Singal A, Wellinf TH, Marrero JA. Role of liver transplantation in the treatment of cholangiocarcinoma. Expert Rev Anticancer Ther. 2009 Apr;9(4):491-502.

Top

Policy History: 

Date                                        Reason                               Action

April 2011                              Annual review                     Policy renewed

March 2012                           Annual review                     Policy renewed

Top

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.