Blue Cross Blue Shield MA Liver Transplant Coverage Update

Coverage Criteria for Liver Transplantation

inv-01: Medically necessary indications

Covered when ALL of the following are met:

General coverage statement: Liver transplant (cadaveric or living donor) may be considered medically necessary for carefully selected individuals with end-stage liver failure due to irreversibly damaged livers; applies to adults and children.

Acceptable etiologies: Indications include hepatocellular diseases (eg, alcoholic liver disease; viral hepatitis; autoimmune hepatitis; alpha-1 antitrypsin deficiency; hemochromatosis; metabolic dysfunction-associated steatohepatitis; porphyria; Wilson disease), cholestatic diseases (eg, primary biliary cirrhosis; primary sclerosing cholangitis with secondary biliary cirrhosis; biliary atresia), vascular disease (eg, Budd–Chiari syndrome), primary hepatocellular carcinoma, inborn errors of metabolism, trauma/toxic liver injury, and other listed miscellaneous indications (eg, familial amyloid polyneuropathy, amyloidosis, cryptogenic cirrhosis, familial cholestasis, Alagille syndrome).

Special indications: Polycystic liver disease with massive hepatomegaly may be considered when liver enlargement causes respiratory compromise, extreme pain, or significant compression/interference with other abdominal organ function; unresectable hilar (extrahepatic) cholangiocarcinoma may be considered; nonmetastatic pediatric hepatoblastoma may be considered.

Retransplantation indications: Retransplantation may be considered for primary graft nonfunction, hepatic artery thrombosis, chronic rejection, ischemic-type biliary lesions after donation after cardiac death (DCD), or recurrent non-neoplastic disease causing late graft failure.

Combined transplant: Combined liver–kidney transplantation may be considered medically necessary in individuals who qualify for liver transplantation and have advanced irreversible kidney disease.

inv-02: Investigational / Not established

Not covered / Investigational in the following situations:

Investigational conditions: Liver transplantation is considered investigational (not established as medically necessary) for intrahepatic cholangiocarcinoma, neuroendocrine tumors metastatic to the liver, hepatic adenoma, unresectable colorectal liver metastases, and epithelioid hemangioendothelioma (HEHE).

inv-03: Evidence-based coverage summaries

Coverage stance summarized from evidence statements in document excerpts

Hepatic epithelioid hemangioendothelioma (HEHE): Evidence consists of nonrandomized observational studies; posttransplant survival similar to other indications but evidence judged insufficient to determine improvement in net health outcome.

Investigational per policy update.

Hepatic adenomas: Evidence includes observational studies and a systematic review reporting approximately 5‑year overall survival of 95% after transplant but lacks optimal selection criteria; evidence judged insufficient to determine improvement in net health outcome.

Investigational per policy update.

Pediatric hepatoblastoma: Case series demonstrate good outcomes and high long‑term survival; nonmetastatic pediatric hepatoblastoma is among UNOS criteria for transplant; evidence sufficient to determine benefit when standard criteria are met.

Covered when transplant meets standard criteria.

Liver transplantation is not covered when there is a known current malignancy, including metastatic cancer, or a recent malignancy with high risk of recurrence unless the transplant team provides a documented justification assessing recurrence risk. Providers requesting transplant for a recently treated malignancy must submit a transplant team statement explaining why the patient is an appropriate candidate. Additionally, transplantation is not covered for patients with untreated systemic infection that would make immunosuppression unsafe (including chronic infection), for other irreversible end‑stage disease not attributable to liver disease, for history of cancer with a moderate risk of recurrence, or for systemic disease that could be exacerbated by immunosuppression.

This policy was updated during the 2/2026 annual review to explicitly designate several indications as investigational. The policy statements were revised to list unresectable colorectal liver metastases, hepatic epithelioid hemangioendothelioma (HEHE), hepatic adenomas, and intrahepatic cholangiocarcinoma as investigational for liver transplantation; investigational indications are not established as medically necessary under this policy.

Liver transplantation is considered investigational (not established as medically necessary) for all clinical situations that are not specifically described as medically necessary in this policy. Requests for transplantation for indications outside the listed medically necessary criteria should be considered investigational and are subject to denial unless adequate evidence and justification are provided.

For hepatic epithelioid hemangioendothelioma (HEHE), the available evidence consists of nonrandomized observational studies; posttransplant survival appears similar to other indications but, given the rarity of the tumor and lack of higher‑quality comparative data, the evidence is insufficient to determine an improvement in net health outcome. For hepatic adenoma, observational studies and a systematic review report a 5‑year overall survival of approximately 95%, but uncertainty about optimal patient selection leaves the evidence insufficient to determine an improvement in net health outcome. These evidence conclusions support the policy designation of these conditions as investigational.

Candidate Selection and Prioritization

inv-24: Candidate selection and prioritization

Prioritization and candidate considerations:

Urgency prioritization: Patients are prioritized by UNOS/OPTN criteria including Status 1A/1B designations and MELD/PELD scores; Status 1A includes acute liver failure with life expectancy fewer than 7 days without transplant.

Candidate selection: Candidates must be carefully selected; program‑level requirements commonly apply (eg, evidence of abstinence and active engagement in substance‑abuse treatment programs for alcohol‑related disease, often a minimum abstinence period), and psychosocial evaluation and capacity for adherence to lifelong immunosuppression are required.

inv-25: Candidate selection for retransplant and combined transplant

Candidates appropriate for retransplantation or combined liver–kidney transplant as summarized from evidence:

Contraindications and Exclusionary Conditions

Contraindications include active malignancy (including metastatic disease) and recent malignancy with a high risk of recurrence when no transplant team justification is provided. Other contraindications include untreated systemic infection that would render immunosuppression unsafe, other irreversible end‑stage diseases not due to liver disease, history of cancer with moderate recurrence risk, and systemic conditions likely to be worsened by immunosuppression. These conditions may result in denial of coverage unless adequate clinical justification and transplant team assessment are submitted.

Psychosocial issues and substance use disorders that impair a patient’s ability to adhere to post‑transplant care are contraindications to transplantation unless addressed. The policy requires active involvement in substance abuse treatment for patients with alcohol‑ or drug‑related liver disease (for example, regular meetings, partial/full‑day programs, or inpatient programs). Policy history (4/2016) clarified that psychosocial conditions or chemical dependency affecting adherence are exclusionary factors and must be documented and addressed before transplantation will be considered.

Preauthorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization / Precertification Required

For services described in this policy, precertification/prior authorization is required for all inpatient liver transplant procedures across products. For outpatient settings, prior authorization requirements vary by product; providers should check product-specific rules and submit authorization requests when applicable.

Applies to inpatient liver transplant services for all products.
Outpatient prior authorization depends on product — verify at time of request.

Denial Risk

Investigational/Excluded Indications May Be Denied

This policy includes investigational indications and exclusions (for example: unresectable colorectal liver metastases, hepatic epithelioid hemangioendothelioma, hepatic adenomas, intrahepatic cholangiocarcinoma, active substance abuse, and certain malignancy-related situations). Requests for liver or combined liver–kidney transplants that fall into investigational or excluded categories may be denied.

Evaluation Requirements and Guideline References

Documentation Required

Assessment of cancer recurrence risk required

The transplant team must assess and document the risk of cancer recurrence for patients with previously treated malignancy and include that evaluation in the authorization request.

Assessment of risk of recurrence is made by the transplant team and must be submitted when requesting transplant for recently treated malignancy.

Documentation Required

Reference AASLD/OPTN guidelines for candidate evaluation

Authorization requests should reference guideline-based evaluations: AASLD adult and pediatric practice guidance and OPTN policies are cited as references for candidate evaluation and workup.

AASLD evaluation guidance for adult and pediatric patients and OPTN policies are listed in the references.
Specific workup steps are guided by these references though not enumerated in the policy excerpt.

Transplant Center Requirements and Network Policies

Billing Rule

Center: inpatient precertification required

Precertification/prior authorization is required for inpatient services and transplant is performed in the inpatient setting for the commercial products referenced.

Inpatient precertification/prior authorization IS REQUIRED for all products.
Commercial product notes indicate the procedure is performed in the inpatient setting.

Note

Center adherence to OPTN and society guidelines implied

References to OPTN policies and professional society guidelines (AASLD, ILTS‑ILCA) imply that transplant centers should adhere to transplant network policies and specialty guidelines when evaluating candidates and performing transplants.

OPTN Policy 9 and AASLD practice guidances are cited in the references.

Coding

Covered CPT CodesCPTCovered

47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age

ICD-10-PCS / Procedure Codes (informational)ICD-10

0FB03ZZ	Excision of Liver, Percutaneous Approach
0FB00ZZ	Excision of Liver, Open Approach
0FB04ZZ	Excision of Liver, Percutaneous Endoscopic Approach
0FB10ZZ	Excision of Right Lobe Liver, Open Approach
0FB13ZZ	Excision of Right Lobe Liver, Percutaneous Approach
0FB14ZZ	Excision of Right Lobe Liver, Percutaneous Endoscopic Approach
0FB20ZZ	Excision of Left Lobe Liver, Open Approach
0FB23ZZ	Excision of Left Lobe Liver, Percutaneous Approach
0FB24ZZ	Excision of Left Lobe Liver, Percutaneous Endoscopic Approach
0FT00ZZ	Resection of Liver, Open Approach

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Post-Transplant Care and Follow-Up

Post-transplant immunosuppression and follow-up — Lifelong management needs

Duration of immunosuppressionLife-long immunosuppression is required to prevent allograft rejection following liver transplantation.

Purpose of follow-upLong-term management focuses on preventing rejection, monitoring graft function, and managing immunosuppression-related complications.

Prioritization contextRecipients are prioritized for transplant by mortality risk and severity criteria developed by OPTN/UNOS (MELD/PELD and Status designations).

Care setting implicationsOngoing outpatient follow-up and specialty care are needed indefinitely after discharge from the transplant hospitalization.

Retransplantation and combined liver-kidney transplantation — Evidence and follow-up

Definition

Definitions and Scoring Systems

MELD / PELD scores

MELD/PELD purposeModel for End-stage Liver Disease (MELD) and Pediatric End-stage Liver Disease (PELD) scores are used to determine severity of liver disease and priority for transplant placement.

Allocation roleFollowing Status 1 priority, donor livers are allocated to patients with the highest MELD or PELD scores due to organ scarcity.

Score applicationMELD applies to adult patients; PELD applies to pediatric patients for objective prioritization on the waiting list.

UNOS priority categories (Status 1A / 1B)

Status 1AUNOS Status 1A: highest priority for acute liver failure (eg, life expectancy <7 days without transplant).

Status 1BUNOS Status 1B: priority category for certain pediatric patients with chronic liver disease.

Background

Liver transplantation is performed as a treatment of last resort for patients with end‑stage liver disease. It can be lifesaving and substantially improve quality of life for selected patients. Recipients require lifelong immunosuppression to prevent rejection, and candidates are prioritized for transplant by urgency using UNOS/OPTN criteria such as MELD/PELD scores and Status 1A/1B designations. Donor strategies include deceased donor, split grafts, and living donor transplantation.

OpenPayer

Liver Transplantation Coverage Criteria