Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesTransplantPHC California Liver Transplant Coverage | OpenPay…
    Ask Trek AI about this page
    ModifiedPositive Healthcare (PHC) California – AIDS Healthcare FoundationPolicy CG-UM-007

    Liver Transplantation

    Customize your policy alerts

    Sign up for phccalifornia Policy CG-UM-007 alerts

    Get alerted when Policy CG-UM-007 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs medical necessity and coverage criteria for whole or partial liver transplantation using deceased or living donors for individuals with end-stage liver disease due to irreversible liver damage. It also addresses liver retransplantation, contraindications, investigational services, and applicable transplant procedure coding.

    Policy Summary
    PayerPositive Healthcare (PHC) California – AIDS Healthcare Foundation
    PolicyLiver Transplantation
    Policy CodePolicy CG-UM-007
    Change TypeModified
    Effective DateN/A
    Last ReviewAug 14, 2025
    Next Review DateN/A
    Key ActionThe transplant facility should complete a medical and psychosocial assessment confirming that transplantation is the best treatment option, establishing the irreversible nature of liver disease, and documenting the lack of effective alternative medical therapy.
    SourceLink
    POLICY UPDATE CHANGES

    The coding section was updated to reflect CPT changes, including removal of CPT 47136 and ICD-9 codes.

    A medically necessary clinical indication for hilar cholangiocarcinoma was added.

    The policy history records updates to medically necessary covered conditions for liver transplantation.

    The investigational and not medically necessary statement was clarified in the document history.

    The coding section was updated to remove CPT 47136 and ICD-9 codes.

    Hilar cholangiocarcinoma was added as a medically necessary clinical indication for liver transplantation.

    Cryptogenic cirrhosis was added to the list of liver diseases leading to end-stage liver failure.

    11,256U.S. candidates listed for liver transplantation in 2022

    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.

    89.1%Reported 1-year liver transplant survival
    MELD 6–40Adult liver allocation score range
    ≤3 cmMaximum hilar cholangiocarcinoma tumor diameter
    CD4 >200HIV/AIDS exception criterion
    InvestigationalXenotransplantation and bioartificial liver devices

    Covered and Non-Covered Liver Transplant Services

    Initial Liver Transplantation

    Covered when all general and disease-specific criteria are met.

    Initial liver transplantation criteria

    • General medical necessity

      • End-stage irreversible liver disease

        • The member has end-stage organ failure due to irreversible liver damage.

      • General selection criteria

        • The member does not have a contraindication under the policy's general individual selection criteria.

    • Accepted underlying condition

      • Cholestatic liver diseases

        • Primary biliary cirrhosis.
        • Primary sclerosing cholangitis.
        • Biliary atresia.
        • Caroli's disease.
        • Familial cholestasis.
        • Arteriohepatic dysplasia (Alagille's disease).
        • Cystic fibrosis.

      • Hepatocellular injury

        • Viral-induced hepatitis.
        • Drug-induced injury, including acetaminophen or injury associated with halothane, gold, disulfiram, or other drugs.
        • Alcohol-induced injury.
        • Amanita mushroom toxin exposure.
        • Autoimmune hepatitis.

      • Inborn errors of metabolism

        • Wilson's disease.
        • Organic acidurias.
        • Hemochromatosis.
        • Alpha-1 antitrypsin deficiency.
        • Homozygous type II hyperlipoproteinemia.
        • Crigler-Najjar syndrome type I.
        • Protoporphyria.

      • Acute disease

        • Fulminant hepatic failure.

      • Mass-occupying lesions

        • Polycystic liver disease requiring transplantation because of anatomic complications.
        • Hepatoblastoma confined to the liver.
        • Primary hepatocellular carcinoma confined to the liver.
        • Hemangioendothelioma.
        • Selected hilar cholangiocarcinoma meeting the additional criteria in this policy.

      • Vascular or other disease

        • Budd-Chiari syndrome.
        • Cryptogenic cirrhosis.

    Hilar Cholangiocarcinoma

    Hilar cholangiocarcinoma transplantation is covered only when all listed conditions are met.

    Selected hilar cholangiocarcinoma criteria

    • The tumor has a cross-sectional or radial diameter of 3 cm or less.≤3 cm
    • Neoadjuvant chemoradiation therapy has been provided.
    • The tumor is unresectable, or underlying liver disease makes the member unsuitable for resection.
    • There is no intrahepatic or extrahepatic metastasis and no nodal disease.

    Liver Retransplantation

    Retransplantation is medically necessary under the following circumstances.

    Liver retransplantation

    • The initial graft has failed because of technical reasons or hyperacute rejection.
    • The graft has failed because of chronic rejection or recurrent disease, and the member meets the general liver transplant selection criteria.

    HIV/AIDS Exception

    HIV/AIDS does not automatically preclude transplantation when all listed conditions are met.

    HIV/AIDS transplant eligibility exception

    • The CD4 count is greater than 200 cells/mm3 for greater than 6 months.CD4 >200 cells/mm3 for >6 months
    • HIV-1 RNA is undetectable.
    • The member has been on stable antiretroviral therapy for greater than 3 months.Stable antiretroviral therapy >3 months
    • There are no other AIDS complications, such as opportunistic infection or neoplasm.

    Liver transplantation for extrahepatic malignancy is considered investigational and not medically necessary, including non-hilar extrahepatic cholangiocarcinoma, intrahepatic cholangiocarcinoma, or hepatocellular carcinoma that extends beyond the liver.

    Liver transplantation is considered investigational and not medically necessary when the underlying condition does not result in end-stage organ failure caused by irreversible liver damage.

    Xenotransplantation—the transplantation of an organ or tissue from an animal species into a human—is considered investigational and not medically necessary.

    Bioartificial liver devices, which use living liver cells in extracorporeal cartridges to provide temporary liver function, are considered investigational and not medically necessary because sufficient evidence supporting their safety and efficacy is not available.

    Liver transplantation for gastrointestinal neuroendocrine tumor metastases is considered investigational and not medically necessary. It is not part of routine care because of the associated risks and the substantial likelihood of recurrence.

    Zooplastic liver transplantation and single or multiple biliary filtration procedures are identified as investigational and not medically necessary under this policy.

    Applicable federal and state law, contract language, definitions, specific contract provisions, and exclusions take precedence over the Medical Policy and must be considered first when determining coverage eligibility. The member’s contract benefits in effect on the date services are rendered control the coverage determination.

    Services and indications expressly designated as investigational and not medically necessary are not medically necessary under this policy. These include transplantation for disallowed malignancy patterns, conditions that do not cause end-stage organ failure from irreversible liver damage, xenotransplantation, and bioartificial liver devices.

    The applicable listed procedure codes are considered investigational and not medically necessary when the policy criteria are not met or when the code describes a procedure identified in the Position Statement as investigational and not medically necessary.

    Position Statement procedures designated investigational and not medically necessary include zooplastic liver transplantation and biliary filtration, whether performed as a single or multiple procedure.

    Transplant Procedure and Diagnosis Coding

    When services may be medically necessary when criteria are met: CPTCPT
    00796Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient).
    47133Donor hepatectomy, (including cold preservation), from cadaver donor.
    47135Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age.
    47140Donor hepatectomy (including cold preservation), from living donor; left lateral segment only.
    47141Donor hepatectomy (including cold preservation), from living donor; left lateral segment only (segments II and III).
    47142Donor hepatectomy (including cold preservation), from living donor; total left lobectomy (segments II, III, IV).
    47143Backbench 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.
    47145Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation.
    CPTCPTCovered
    00796Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient).
    47133Donor hepatectomy, including cold preservation, from cadaver donor.
    47135Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age.
    47140Donor hepatectomy, including cold preservation, from living donor; left lateral segment only.
    47141Donor hepatectomy, including cold preservation, from living donor; left lateral segment only (segments II and III).
    47142Donor hepatectomy, including cold preservation, from living donor; total right lobectomy (segments V, VI, VII and VIII).
    47143Backbench 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.
    47145Backbench 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.
    47146Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each.
    47147Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each.
    ICD-10 ProcedureICD-10Covered
    0FT00ZZResection of liver, open approach
    0FT04ZZResection of liver, percutaneous endoscopic approach
    0FY00Z0Transplantation of liver, allogeneic, open approach
    0FY00Z1Transplantation of liver, syngeneic, open approach
    ICD-10 DiagnosisICD-10
    All diagnosesAll diagnoses
    Investigational and Not Medically Necessary ICD-10 ProcedureICD-10Experimental
    0FY00Z2Transplantation of liver, zooplastic, open approach
    5A1C00ZPerformance of biliary filtration, single
    5A1C60ZPerformance of biliary filtration, multiple
    Investigational and Not Medically Necessary ICD-10 DiagnosisICD-10Experimental
    All diagnosesAll diagnoses
    Removed CPT CodesCPT
    47136CPT code identified in the document history as removed because it was deleted
    Hilar cholangiocarcinoma tumor diameter
    Maximum diameter3 cm or less in cross-sectional or radial diameter
    Additional treatmentNeoadjuvant chemoradiation therapy is required
    Disease statusThe tumor must be unresectable or underlying liver disease must make the individual unsuitable for resection
    UNOS hepatocellular carcinoma lesion criteria
    AFP level≤1000 ng/mL

    Documentation, Referral, and Coverage Risk

    Documentation Required

    Complete Medical and Psychosocial Transplant Evaluation

    Before transplantation, the transplant facility should complete and document a formal medical and psychosocial assessment confirming that transplantation is the best treatment option, that the liver disease is irreversible, and that no effective alternative medical therapy remains. The assessment must also include review of contraindications and the member’s overall candidacy.

    • Document the transplant facility’s medical and psychosocial evaluation.
    • Confirm irreversible liver disease and lack of effective alternative treatment.
    • Review and document contraindications before referral or authorization.
    Denial Risk

    Investigational or Non-Covered Indications

    Liver transplantation is investigational and not medically necessary for extrahepatic malignancy, including non-hilar extrahepatic cholangiocarcinoma, intrahepatic cholangiocarcinoma, or hepatocellular carcinoma extending beyond the liver. It is also investigational and not medically necessary for conditions that do not cause end-stage organ failure from irreversible liver damage, xenotransplantation, and bioartificial liver devices.

    Liver Transplantation Overview

    Liver transplantation replaces an end-stage diseased liver with a whole or partial graft from a deceased or living donor. Orthotopic transplantation places the graft in the liver’s normal anatomic location and is the predominant approach. Split-liver transplantation may divide one donor liver into grafts for two recipients.

    Key Transplant Terms

    End-stage
    TermEnd-stage
    MeaningBeing or occurring in the final stages
    Clinical contextThe final stages of a terminal disease or condition
    Fulminant liver failure
    TermFulminant liver failure
    Defining eventOnset of hepatic encephalopathy
    Time frameWithin 8 weeks of the first symptoms of liver disease

    General Liver Transplant Candidacy

    General Liver Transplant Candidacy

    A liver transplant candidate must have end-stage irreversible liver disease, satisfy disease-specific criteria, complete medical and psychosocial evaluation, and have no disqualifying contraindication.

    General liver transplant candidacy

    • The member has end-stage liver disease from irreversible liver damage.
    • The disease-specific indication is covered.
    • Effective medical treatment has been attempted, or no effective alternative medical treatment exists.
    • The transplant facility has completed a medical and psychosocial assessment confirming that transplantation is the best treatment option.

    Transplant Contraindications

    Transplant candidacy may be limited by metastatic cancer; ongoing or inadequately treated infection, including uncontrolled sepsis; serious cardiac or pulmonary disease that prevents surgery; or other serious conditions unlikely to improve with transplantation. Additional concerns include demonstrated noncompliance, unacceptable immunosuppression risks, AIDS without meeting the policy exception, ongoing alcohol or illicit substance abuse, anatomic barriers, hepatocellular carcinoma with metastatic spread, intrahepatic cholangiocarcinoma, hemangiosarcoma, and inadequate social support.

    Required Pre-Transplant Evaluation

    Documentation Required

    Document all evaluation prerequisites

    Complete a formal medical and psychosocial assessment before transplantation. Confirm the irreversible nature of the liver disease, establish that effective alternative medical treatment is unavailable or has been attempted, review contraindications, and determine that transplantation is the best treatment option.

    • Complete the assessment before transplantation.
    • Confirm irreversible liver disease.
    • Document that effective alternative medical treatment is unavailable or has been attempted.
    • Review contraindications and confirm transplantation is the best treatment option.
    Policy Summary
    PayerPositive Healthcare (PHC) California – AIDS Healthcare Foundation
    PolicyLiver Transplantation
    Policy CodePolicy CG-UM-007
    Change TypeModified
    Effective DateN/A
    Last ReviewAug 14, 2025
    Next Review DateN/A
    Key ActionThe transplant facility should complete a medical and psychosocial assessment confirming that transplantation is the best treatment option, establishing the irreversible nature of liver disease, and documenting the lack of effective alternative medical therapy.
    SourceLink
    On This Page
    Covered and Non-Covered Liver Transplant ServicesTransplant Procedure and Diagnosis CodingDocumentation, Referral, and Coverage RiskLiver Transplantation OverviewKey Transplant TermsGeneral Liver Transplant CandidacyTransplant ContraindicationsRequired Pre-Transplant Evaluation
    Selected urea cycle deficiencies.
  1. Glycogen storage disease types I or IV.
  2. Tyrosine deficiency.
  3. Citrullinemia.
  4. Ornithine transcarboxylase deficiency.
  5. Familial amyloid polyneuropathy.
  6. Primary oxalosis.
    7. All other liver transplantation criteria are met.
    Single-lesion pattern
    One lesion measuring ≥2 cm and ≤5 cm
    Multiple-lesion patternTwo or three lesions, each measuring ≥1 cm and ≤3 cm
    HIV immune status
    CD4 count>200 cells/mm3
    DurationThe CD4 count must remain above 200 cells/mm3 for greater than 6 months
    Additional HIV criteriaHIV-1 RNA must be undetectable, stable antiretroviral therapy must exceed 3 months, and no other AIDS complications may be present
    Alcohol-associated liver disease referral trigger
    Alcohol-associated cirrhosis triggerDecompensated alcohol-associated cirrhosis, including Child-Pugh-Turcotte class C cirrhosis
    MELD-Na triggerMELD-Na score ≥21
    Recommended actionThese characteristics should trigger evaluation and consideration for liver transplantation
    Adult MELD score range
    Adult score rangeMELD 6 to 40
    Lower endA score of 6 indicates less severe illness
    Upper endA score of 40 indicates grave illness
    • Do not authorize transplantation for malignancy extending beyond the liver.
    • Do not authorize transplantation for non-hilar extrahepatic cholangiocarcinoma or intrahepatic cholangiocarcinoma.
    • Treat xenotransplantation and bioartificial liver devices as investigational and not medically necessary.
    • Confirm that the indication causes end-stage organ failure due to irreversible liver damage.
    Denial Risk

    Screen for Contraindications and Poor Candidacy

    In addition to end-stage liver disease, the member must not have a contraindication identified in applicable transplant-selection guidance. Conditions that may preclude a successful outcome or make transplantation medically inappropriate can result in coverage denial unless the record supports an exception or individual review.

    • Assess for metastatic cancer, uncontrolled or recurrent infection, uncontrolled sepsis, and serious cardiac or pulmonary disease that prevents tolerance of surgery.
    • Assess for conditions unlikely to improve with transplantation, anatomic abnormalities precluding transplantation, hemangiosarcoma, or hepatocellular carcinoma with metastatic spread.
    • Assess ongoing alcohol or illicit substance abuse, persistent noncompliance, and lack of adequate social support.
    • Assess whether immunosuppressive complications are unacceptable to the member.
    • For AIDS, document CD4 count greater than 200 cells/mm³ for more than 6 months, undetectable HIV-1 RNA, stable antiretroviral therapy for more than 3 months, no AIDS complications, and satisfaction of all other transplant criteria.
    • Consider MELD score below 15, intrahepatic cholangiocarcinoma, extrahepatic malignancy, and fulminant hepatic failure in candidacy review.
    Prior Authorization

    Apply Criteria to Each Requested Organ

    For a multi-organ transplant request, the coverage criteria must be met independently for each organ requested. If a concurrent condition would otherwise be an exclusion or comorbidity that could preclude a successful outcome but would be treated by the additional organ transplant, the case requires individual review to determine coverage and transplant candidacy.

    • Submit documentation supporting medical necessity for every requested organ.
    • Identify concurrent conditions, exclusions, and comorbidities that may affect transplant success.
    • Refer cases involving potentially treatable exclusions or comorbidities for individual coverage determination.
    Prior Authorization

    Verify Hilar Cholangiocarcinoma Limitations

    Hilar cholangiocarcinoma is limited to highly selected candidates. Coverage requires a tumor measuring 3 cm or less in cross-sectional or radial diameter, neoadjuvant chemoradiation or other required neoadjuvant therapy before transplantation, and either unresectable disease or underlying liver disease that makes the member ineligible for resection; there must be no intrahepatic or extrahepatic metastases or nodal disease.

    • Confirm tumor diameter is ≤ 3 cm.
    • Document neoadjuvant therapy before transplantation.
    • Confirm unresectable disease with otherwise normal biliary and hepatic function, or underlying chronic liver disease precluding surgery.
    • Document absence of intrahepatic metastases, extrahepatic metastases, and nodal disease.
    • Do not treat liver transplantation for hilar cholangiocarcinoma outside these highly selected circumstances as meeting medical-necessity criteria.
    Denial Risk

    Criteria Not Met or Investigational Procedure

    When the applicable criteria are not met, or when the procedure describes an indication identified as investigational and not medically necessary, the listed procedure codes are not medically necessary for coverage purposes.

    • Verify that the requested procedure code corresponds to an indication meeting the policy criteria.
    • Apply denial or non-coverage when criteria are not met or the indication is investigational and not medically necessary.
    Billing Rule

    Contract and Legal Provisions Control Eligibility

    Federal and state law and the member’s contract, including definitions, specific provisions, and exclusions, take precedence over Medical Policy and must be considered first when determining eligibility. Use the contract benefits in effect on the date services are rendered; medical policy and medical opinion are considered only after applicable legal and contractual provisions.

    • Review federal and state law before applying policy criteria.
    • Review the member’s contract language, definitions, provisions, and exclusions.
    • Apply benefits in effect on the date services are rendered.
    • Use Medical Policy to address medical efficacy after controlling legal and contractual provisions.
    Extrahepatic disease
    TermExtrahepatic disease
    Disease typeCancer
    LocationOutside of the liver
    MELD
    AbbreviationMELD
    Full nameModel for End-Stage Liver Disease
    Use in policyA numerical liver-disease severity score used for adult allocation, ranging from 6 to 40
    PELD
    AbbreviationPELD
    Full namePediatric end-stage liver disease
    PopulationUsed for pediatric liver transplant allocation
    Orthotopic
    TermOrthotopic
    MeaningRelating to the grafting of tissue
    PositionIn a natural position
    Heterotopic
    TermHeterotopic
    MeaningGrafted or transplanted
    PositionInto an abnormal position
    Xenotransplantation
    TermXenotransplantation
    SourceAn organ or tissue is removed from an animal species
    RecipientThe organ or tissue is transplanted into a human
    The member has no absolute contraindication to transplantation.