A liver transplant using a cadaver or living donor may be considered medically necessary for carefully selected individuals with end-stage liver failure due to irreversibly damaged livers. Etiologies of end-stage liver disease include, but are not limited to, the following.
A. Hepatocellular diseases
Alcoholic liver disease
Viral hepatitis (either A, B, C, or non-A, non-B)
Autoimmune hepatitis
α1-Antitrypsin deficiency
Hemochromatosis
Nonalcoholic steatohepatitis
Protoporphyria
Wilson disease.
B. Cholestatic liver diseases
Primary biliary cirrhosis
Primary sclerosing cholangitis with development of secondary biliary cirrhosis
Biliary atresia.
C. Vascular disease
Budd-Chiari syndrome.
D. Primary hepatocellular carcinoma (see Policy Guidelines section for individual selection criteria).
E. Inborn errors of metabolism.
F. Trauma and toxic reactions.
G. Miscellaneous
Familial amyloid polyneuropathy.
Liver transplantation may be considered medically necessary in individuals with polycystic disease of the liver who have massive hepatomegaly causing obstruction or functional impairment.
Liver transplantation may be considered medically necessary in individuals with unresectable hilar cholangiocarcinoma (see Policy Guidelines section for individual selection criteria).
Liver transplantation may be considered medically necessary in pediatric individuals with nonmetastatic hepatoblastoma.
Liver retransplantation may be considered medically necessary in individuals with:
primary graft nonfunction
hepatic artery thrombosis
chronic rejection
ischemic type biliary lesions after donation after cardiac death
recurrent non-neoplastic disease-causing late graft failure.
Combined liver-kidney transplantation may be considered medically necessary in individuals who qualify for liver transplantation and have advanced irreversible kidney disease.
Liver transplantation is investigational in the following situations:
Individuals with intrahepatic cholangiocarcinoma
Individuals with neuroendocrine tumors metastatic to the liver.
Liver transplantation is considered not medically necessary in the following individuals:
Individuals with hepatocellular carcinoma that has extended beyond the liver (see Policy Guidelines section for individual selection criteria)
Individuals with ongoing alcohol and/or drug abuse. (Evidence for abstinence may vary among liver transplant programs, but generally a minimum of 3 months is required).
Liver transplantation is considered investigational in all other situations not described above.
