![]() ![]() Unstable alcohol or substance use disorder (Exception to this contraindication will be allowed with supporting documentation (within 4 weeks) demonstrating 3 months of stability from treating addiction medical professional or psychiatrist).Presence of significant organ system failure other than kidney, liver or small bowel.Other effective medical treatments or surgical options are available.Active sepsis outside the biliary tract.Intrapulmonary vascular dilatation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography).Īetna considers retransplantation following a failed liver transplant medically necessary if the initial transplant was performed for a covered indication.Īetna considers liver transplantation not medically necessary for members with any of the following absolute contraindications to liver transplantation:.Chronic liver disease with non-cirrhotic portal hypertension and.Arterial hypoxemia (PaO 2 less than 60 mm Hg or AaO 2 gradient greater than 20 mm Hg in supine or standing position) and.Hepato-pulmonary syndrome when the following selection criteria are met:.Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen (Tylenol) overdose, etc.).Porto-pulmonary hypertension (pulmonary hypertension associated with liver disease or portal hypertension) in persons with a mean pulmonary artery pressure by catheterization of less than 35 mm Hg.Metabolic disorders and metabolic liver diseases with cirrhosis (not an all-inclusive list).Metastatic neuroendocrine tumors (carcinoid tumors, apudomas, gastrinomas, glucagonomas) in persons with severe symptoms and with metastases restricted to the liver, who are unresponsive to adjuvant therapy after aggressive surgical resection including excision of the primary lesion and reduction of hepatic metastases.Large, unresectable fibrolamellar HCCs.Intra-hepatic cholangiocarcinomas (i.e., cholangiocarcinomas confined to the liver).There is no identifiable extra-hepatic spread of tumor to surrounding lungs, abdominal organs, bone or other sites Note: Spread of hepatoblastoma to veins and lymph nodes does not disqualify a member for coverage of a liver transplant.Hepatoblastomas in members less than 12 years of age when all of the following criteria are met: ![]() Note: These criteria are intended to be consistent with UNOS guidelines for selection of liver transplant candidates for hepato-cellular carcinoma (HCC). There is no identifiable extra-hepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites and.Member meets UNOS criteria for tumor size and number and.Member is not a candidate for subtotal liver resection and.Any lung metastases that have been shown to be responsive to chemotherapy and.Primary hepatocellular carcinoma confined to the liver when all of the following criteria are met: Post-necrotic cirrhosis due to hepatitis B surface antigen negative state.Chronic active hepatitis with cirrhosis (hepatitis B or C).Primary sclerosing cholangitis with development of secondary biliary cirrhosis.Medically Necessary Indications (not an all-inclusive list)Īetna considers orthotopic (normal anatomical position) liver transplantation (with cadaveric organ, reduced-size organ, living related organ, and split liver) medically necessary for members with end-stage liver disease (ESLD) due to any of the following conditions who meet medical necessity criteria in Section I.A.:.In the absence of an institution's selection criteria, requests for liver transplantation are subject to medical necessity review for children, and for adolescents and adults with a MELD score of 10 or less who have not been approved by the UNOS Regional Review Board. Children less than 12 years of age who meet the transplanting institution's selection criteria.who meet the transplant institution's selection criteria and.who are approved for transplant by the United Network for Organ Sharing (UNOS) Regional Review Board or.a Model of End-stage Liver Disease (MELD) score (see Appendix) greater than 10 or.Adolescents 12 years of age or older and adults with either:.Aetna considers liver transplantation medically necessary for the indications listed below in Section I.B.This Clinical Policy Bulletin addresses liver transplantation. Number: 0596 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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