Liver transplant and combined liver-kidney transplant
Customize your policy alerts
Sign up for Capital Bluecross Policy MP 9.006 alerts
Get alerted when Policy MP 9.006 changes without checking for updates manually.
Monitor payer policy activity
This policy governs medical necessity and selection criteria for cadaveric and living-donor liver transplantation, including combined liver-kidney transplant, and applies to Capital BlueCross-covered individuals undergoing evaluation or listing for transplant.
No material clinical or coverage changes in this revision.
Coverage Criteria for Liver and Combined Liver-Kidney Transplant
Medically necessary indications
Covered when ALL of the following are met for standard indications
Investigational or not medically necessary indications
Investigational / Not routinely covered when ANY of the following apply
Hepatocellular carcinoma
Hepatocellular carcinoma selection logic (candidate must meet one set below and have disease confined to liver)
Use of locoregional therapies to downstage or prevent progression is encouraged per allocation guidance.
Cholangiocarcinoma
Cholangiocarcinoma exception pathway
Serial imaging every 3 months required for exception increases.
Indication-specific coverage
Coverage determinations summarized by indication
Survival lower in viral hepatitis but may improve with viral eradication pre-transplant.
Standardized selection criteria (eg, Milan) improve outcomes.
Further studies needed to define selection criteria.
UNOS listing criteria include pediatric hepatoblastoma.
Outcomes may be less favorable than primary transplant in some cases.
Pediatric CLKT indications are rare and often congenital.
Liver transplantation is designated investigational for the listed indications when any of the specified conditions apply. Specifically, transplantation is considered investigational for individuals with intrahepatic cholangiocarcinoma and for individuals with neuroendocrine tumors metastatic to the liver. The policy also identifies transplantation as investigational for hepatocellular carcinoma that has extended beyond the liver and for individuals with ongoing alcohol and/or drug abuse (with most programs requiring at least 3 months of abstinence).
Evidence for liver transplantation in intrahepatic cholangiocarcinoma is limited to registry and observational data; some series report 5‑year survival rates <30%. Because the available studies are heterogeneous and do not demonstrate consistent meaningful improvement in health outcomes, the policy concludes that the evidence is insufficient to support transplantation as a routine therapeutic option for intrahepatic cholangiocarcinoma.
Policy history entries document periodic editorial and administrative updates without changes to the intent of the coverage statements. The policy disclaimer reiterates that these medical policies guide coverage determinations but do not constitute medical advice, and final claim payment depends on member benefits and eligibility. The excerpted policy history and disclaimer do not introduce additional exclusion language beyond the coverage statements already summarized.
The policy explicitly lists the following indications as investigational: intrahepatic cholangiocarcinoma and neuroendocrine tumors metastatic to the liver. It also states transplantation is investigational for HCC with extrahepatic extension and for individuals with ongoing substance abuse, reflecting insufficient evidence or programmatic selection concerns for these indications.
For select indications—notably intrahepatic cholangiocarcinoma and metastatic neuroendocrine tumors—the policy highlights that current data (registry studies, observational series, and systematic reviews of case series) are limited and heterogeneous. As a result the policy characterizes the evidence as insufficient to determine the effects of transplantation on net health outcomes for these populations.
The portions of the document cited here do not present an explicit separate section labeled ‘not medically necessary’ beyond describing indications considered investigational or unsupported by sufficient evidence. Policy history and administrative notes describe updates and editorial refinements but do not add an explicit 'not medically necessary' statement in the excerpted text.
Candidate Selection and Eligibility Criteria
General candidacy
General candidate considerations
Candidacy is individualized when coexisting cardiac disease or other nonhepatic organ dysfunction is present.
HCC candidacy
HCC-specific candidate criteria
Progression beyond T2 results in loss of additional allocation priority.
Candidate considerations by organ type
Indication-specific candidate considerations summarized from evidence statements
Use of standardized selection criteria improves outcomes.
OPTN/UNOS exception processes apply.
Evidence suggests CLKT is no worse and possibly better for graft and patient survival in selected cases.
Contraindications That May Preclude Transplant
Contraindications that may preclude transplantation include current malignancy (including metastatic cancer), recent malignancy with high risk of recurrence, and untreated systemic infection that would make immunosuppression unsafe. Other listed considerations include other irreversible end‑stage disease not attributed to liver disease, systemic disease exacerbated by immunosuppression, and psychosocial or chemical dependency
Potential contraindications noted in the policy emphasize center judgment and include known current malignancy and recent malignancy with high recurrence risk, recognizing these clinical conditions as situations that may lead to denial of transplant coverage.
The policy lists untreated systemic infection (including chronic infection) among contraindications, reflecting that active infections rendering immunosuppression unsafe are generally exclusionary for transplantation candidacy.
Other conditions described as potential contraindications include irreversible end‑stage disease not attributed to liver disease and systemic illnesses that could be worsened by post‑transplant immunosuppression; these are intended to guide individualized clinical judgment.
The policy additionally identifies a history of cancer with a moderate risk of recurrence and systemic diseases that could be exacerbated by immunosuppression as factors that may contraindicate transplantation in specific patients.
Psychosocial conditions and chemical dependency that impair the individual’s ability to adhere to complex post‑transplant therapy are listed as potential contraindications and may influence coverage decisions.
The policy frames these contraindications as potential exclusionary factors to be assessed by the transplant center rather than as absolute, unilateral denials—emphasizing clinical judgment in individual cases.
Within the excerpted policy text there is no comprehensive list of absolute contraindications; instead, the document states that coverage determinations are subject to medical necessity assessment and the member’s benefit program, and that transplant candidacy decisions rest with the treating transplant center and payer evaluation.
Pre-Transplant Evaluation and Monitoring Requirements
MELD/PELD exception: submit OPTN/UNOS protocol and documentation
For candidates with hilar (extrahepatic) cholangiocarcinoma seeking MELD/PELD exception points, the transplant center must submit a written center protocol to OPTN/UNOS that includes selection criteria, neoadjuvant therapy details, and operative staging; diagnostic criteria such as a malignant-appearing stricture plus CA19-9 ≥100 U/mL or biopsy/cytology or aneuploidy must be documented; imaging must show a mass <3 cm and exclude intra- and extrahepatic metastases; serial cross-sectional imaging of the chest and abdomen to exclude metastases is required at initial exception and every 3 months for exception increases.
- Center must submit written protocol to OPTN/UNOS with selection criteria, neoadjuvant therapy, and operative staging.
- Document diagnostic criteria: malignant-appearing stricture plus CA19-9 ≥100 U/mL, or biopsy/cytology, or aneuploidy.
- Mass <3 cm on imaging and exclusion of intra- and extrahepatic metastases required.
- Serial chest and abdomen cross-sectional imaging at initial exception and every 3 months for exception increases.
Procedure coding and prior-authorization: use listed transplant codes and verify medical necessity
Obtain and bill using the transplant procedure and associated codes listed in the policy coding section; prior authorization and medical necessity verification are required per member benefit and payer processes. The policy’s code list (e.g., 47399, 47135, S2152, 47140–47147) may not be all-inclusive and identification of a code in the list does not by itself guarantee coverage.
Prior authorization process not specified in policy excerpt — follow payer/member rules
Prior authorization procedures and specific prior-authorization codes are not provided in this document excerpt; providers must follow member benefit and payer-specific prior authorization processes for transplant services.
- This policy excerpt does not include explicit prior-authorization procedures or required prior-authorization codes.
- Follow member benefit and payer-specific prior-authorization workflows.
Contraindications that may lead to denial
Active untreated systemic infection, current malignancy or recent malignancy with high recurrence risk, irreversible non-liver end-stage disease, systemic disease that would be worsened by immunosuppression, or psychosocial/chemical dependency affecting adherence are listed as potential contraindications that may lead to denial of transplant coverage.
- Active untreated systemic infection.
- Current malignancy or recent malignancy with high risk of recurrence.
- Other irreversible end-stage disease not due to liver disease.
- Systemic disease that would be exacerbated by immunosuppression.
- Psychosocial issues or chemical dependency affecting adherence.
Verify benefit, eligibility and medical necessity before proceeding
Verify member benefit coverage, eligibility on the date of service, and that the requested transplant services meet medical necessity; coverage and payment remain subject to the member's benefit program and adjudication of medical necessity.
- Confirm member benefit program covers the requested transplant service.
- Verify eligibility on date of service.
- Document and confirm services meet medical necessity for coverage.
No explicit denial triggers listed in excerpt — still document contraindications and eligibility
The policy does not enumerate explicit denial triggers in this excerpt; however, absence of explicit triggers here does not replace the need to document contraindications, eligibility, and medical necessity per policy statements.
- No explicit denial triggers are stated in this portion of the document.
- Providers must still document contraindications, eligibility, and medical necessity as described elsewhere in the policy.
Provider Actions, Documentation, and Authorization
Submit center protocol and diagnostic documentation for cholangiocarcinoma MELD/PELD exceptions
When requesting a MELD/PELD exception for hilar cholangiocarcinoma, submit the center's written protocol to OPTN/UNOS that includes selection criteria, administration of neoadjuvant therapy, and operative staging, and provide documented diagnostic criteria (eg, malignant-appearing stricture plus CA 19-9 ≥100 U/mL, biopsy/cytology, or aneuploidy).
Procedure codes listed; prior authorization and medical necessity verification required per benefits
Use the procedure and billing codes listed in the policy's coding section when applicable; prior authorization and medical necessity verification are required per member benefit and payer processes.
- Policy lists transplant-related procedure codes and notes that coding may not be all-inclusive.
No explicit prior-authorization procedures or codes specified in this document
Note that this policy excerpt does not provide explicit prior-authorization procedures or required prior-authorization codes; follow payer-specific prior authorization processes as applicable.
Tumor downstaging and locoregional therapy discussed; no mandated constraints
Tumor downstaging and use of locoregional therapies for HCC are discussed as strategies to meet transplant selection criteria or maintain eligibility, but the policy does not mandate specific downstaging protocols or step therapy requirements.
No additional provider action listed
Additional provider action: none specified in this inventory item.
No step therapy required
There are no step therapy requirements specified in this policy section.
Center must submit OPTN/UNOS protocol with selection and neoadjuvant details for CCA exceptions
For cholangiocarcinoma MELD/PELD exceptions, centers must submit a written protocol to OPTN/UNOS that details selection criteria, neoadjuvant therapy administration, and operative staging as part of the exception process.
Document medical necessity; coding presence does not guarantee coverage
Document medical necessity in the medical record; the policy notes that the code list may not be exhaustive and that identifying a code in the policy does not guarantee coverage—final claim payment depends on member benefit terms and eligibility.
Use listed ICD-10-CM diagnosis codes (including T86.41–T86.49, Z52.6) and apply proper sequencing
Use the ICD-10-CM diagnosis codes listed in the policy for liver transplant, transplant complications (eg, T86.41–T86.49), and donor status (Z52.6) when submitting claims and ensure appropriate diagnosis sequencing.
Contraindications that may trigger denial (infection, current/recent high‑risk malignancy, systemic disease, psychosocial issues)
Be aware that potential contraindications may lead to denial, including active untreated systemic infection, current malignancy or recent malignancy with high recurrence risk, other irreversible end-stage disease not due to liver disease, systemic disease exacerbated by immunosuppression, or psychosocial/chemical dependency affecting adherence.
Verify member benefits, eligibility, and medical necessity before proceeding
Verify member benefit coverage, eligibility on the date of service, and that services meet medical necessity criteria—coverage and payment are subject to the member's benefit program and claim adjudication.
No additional explicit denial triggers stated in this section
This section of the document does not list explicit denial triggers beyond the contraindications and coverage verification noted elsewhere.
Coding: Procedure and Diagnosis Codes
| 47399 | Covered when medically necessary (listed in conjunction with other procedure codes) |
| 47135 | Covered when medically necessary (paired with 47399) |
| S2152 | Covered when medically necessary (listed with 47399 and 47135/47140) |
| 47140 | Covered when medically necessary (listed with 47399) |
| 47141 | Covered when medically necessary (listed with 47399) |
| 47142 | Covered when medically necessary (listed with 47399) |
| 47143 | Covered when medically necessary (listed with 47399) |
| 47144 | Covered when medically necessary (listed with 47399) |
| 47145 | Covered when medically necessary (listed with 47399) |
| 47146 | Covered when medically necessary (listed with 47399) |
| B15.0 | Hepatitis A with hepatic coma |
| B15.9 | Hepatitis A without hepatic coma |
| B16.0 | Acute hepatitis B with delta-agent with hepatic coma |
| B16.1 | Acute hepatitis B with delta-agent without hepatic coma |
| B16.2 | Acute hepatitis B without delta-agent with hepatic coma |
| B16.9 | Acute hepatitis B without delta-agent and without hepatic coma |
| B17.0 | Acute delta-(super) infection of hepatitis B carrier |
| B17.10 | Acute hepatitis C without hepatic coma |
| B17.11 | Acute hepatitis C with hepatic coma |
| B17.2 | Acute hepatitis E |
| K71.51 | Toxic liver disease with chronic active hepatitis without ascites |
| K71.6 | Toxic liver disease with chronic active hepatitis with ascites / Toxic liver disease with hepatitis, not elsewhere classified |
| K71.7 | Toxic liver disease with fibrosis and cirrhosis of liver |
| K71.8 | Toxic liver disease with other disorders of liver |
| K71.9 | Toxic liver disease, unspecified |
| K74.1 | Hepatic sclerosis |
| K74.2 | Hepatic fibrosis with hepatic sclerosis |
| K74.3 | Primary biliary cirrhosis |
| K74.4 | Secondary biliary cirrhosis |
| K74.5 | Biliary cirrhosis, unspecified |
| K83.1 | Obstruction of bile duct |
| M34.83 | Systemic sclerosis with polyneuropathy |
| Q44.2 | Atresia of bile ducts |
| Q44.6 | Cystic disease of liver |
| S36.112A | Contusion of liver, initial encounter |
| S36.112D | Contusion of liver, subsequent encounter |
| S36.114A | Minor laceration of liver, initial encounter |
| S36.114D | Minor laceration of liver, subsequent encounter |
| S36.115A | Moderate laceration of liver, initial encounter |
| S36.115D | Moderate laceration of liver, subsequent encounter |
Center and Program Requirements for Exception Requests
Submit written center protocol to OPTN/UNOS for CCA exception submissions
Centers requesting cholangiocarcinoma exceptions must submit a written protocol to OPTN/UNOS that includes selection criteria, neoadjuvant therapy plans, and operative staging procedures as described by OPTN policy.
Center protocol submission required (repeat)
Repeated: centers must provide and submit a written protocol to OPTN/UNOS detailing selection criteria, neoadjuvant therapy, and operative staging when requesting cholangiocarcinoma exceptions.
Coordinate with BQCT and UNOS/OPTN for center and exception processes
Coordinate with Blue Quality Centers for Transplant (BQCT) and follow UNOS/OPTN policies and data collection requirements when participating in transplant programs and submitting exception protocols.
Center protocol requirement reiterated
Repeated center protocol requirement: ensure the protocol submitted to OPTN/UNOS includes selection criteria, neoadjuvant therapy, and operative staging for cholangiocarcinoma exception candidates.
Post-Transplant Care, Immunosuppression, and Complication Management
Key Definitions and Scoring Systems
Background and Scope
Liver transplantation is a life‑saving treatment option for selected patients with end‑stage liver disease from diverse etiologies. Candidates are prioritized using MELD/PELD scores (range described from 6–40) or urgent status (eg, 1A/1B), and recipients require lifelong immunosuppression and ongoing surveillance after transplant. Living‑donor and split‑graft approaches expand the donor pool and permit elective timing to avoid clinical deterioration.
Coding Notes and Claims Guidance
Document medical necessity; code lists non‑exhaustive and do not guarantee coverage
Providers must document medical necessity in the medical record; the policy cautions that the provided code lists are not exhaustive and identifying a code does not guarantee coverage—final claim determination depends on member benefit terms.
Use listed ICD-10-CM diagnosis codes for transplant claims and sequence appropriately
When filing claims, use the diagnosis codes enumerated in the policy for transplant indications, complications, and donor status (examples include K74 series, T86.41–T86.49, and Z52.6) and ensure appropriate diagnosis sequencing for claim processing.
Policy Maintenance and Revision History
Clinical benefit added to the policy.
Consensus review with no change to policy statements; references reviewed and coding reviewed with no coding changes.
Consensus review with editorial refinements to the policy statement; intent unchanged and background, rationale, and other sections updated.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.