Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

QualChoice maintains a national network of Centers of Excellence for members who require transplantation.

 

Transplants and transplant related services are covered only when performed at a transplant center previously approved by QualChoice.

1. Progressive liver diseases that can result in death either in short-term or long-term is known as end-stage liver disease (ESLD).
2. ESLD is treated with transplantation of the liver.
3. Liver transplantation requires pre-authorization.

1.    Orthotopic (normal anatomical position) liver transplantation (with cadaver organ, reduced-size organ, living related organ, and split liver) is considered medically necessary for members with end-stage liver disease (ESLD) for:

A.   Adolescents (12 years to 18 years) and adults who meet the specific criteria below and
with either;

                                    I.        A Model of End-stage Liver Disease (MELD) score (MELD calculator) greater than 10; or

                                  II.        Who are approved for transplant by the United Network for Organ Sharing (UNOS) Regional Review Board.

B.   For children less than 12 years of age who meet the transplanting institution`s selection criteria and the specific criteria below.  The transplant and transplant related services will only be covered if the transplant center is an approved QualChoice provider.

2.    Specific criteria:

A.   Cholestatic diseases:

                                                  i.    Biliary atresia

                                                ii.    Familial cholestatic syndromes

                                               iii.    Primary biliary cirrhosis

                                               iv.    Primary sclerosing cholangitis with development of secondary biliary cirrhosis

B.   Hepatocellular diseases:

                                                  i.    Chronic active hepatitis with cirrhosis (hepatitis B or C)

                                                ii.    Cryptogenic cirrhosis

                                               iii.    Idiopathic autoimmune hepatitis

                                               iv.    Post necrotic cirrhosis due to hepatitis B surface antigen negative state

                                                v.    Alcoholic cirrhosis

C.   Malignancies:

                                                  i.    Primary hepatocellular carcinoma confined to the liver when all of the following criteria are met:

1.    Member is not a candidate for subtotal liver resection; and

2.    Member meets UNOS criteria for tumor size and number; and

3.    There is no macrovascular involvement; and

4.    Any lung metastases have been shown to be responsive to chemotherapy; and

5.    There is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites.

Note: These criteria are intended to be consistent with United Network for Organ Sharing (UNOS) guidelines for selection of liver transplant candidates for hepatocellular carcinoma.

                                                ii.    Hepatoblastomas in children when all of the following criteria are met:

1.    Member is not a candidate for subtotal liver resection; and

2.    The member meets UNOS criteria for tumor size and number; and

3.    There is no identifiable extrahepatic 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.)

                                               iii.    Intrahepatic cholangiocarcinomas (i.e., cholangiocarcinomas confined to the liver);

                                               iv.    Large, unresectable fibrolamellar hepatocellular carcinomas;

                                                v.    Epithelioid hemangioendotheliomas (EHE);

                                               vi.    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.

D.   Vascular diseases:

                                                  i.    Budd-Chiari syndrome

                                                ii.    Veno-occlusive disease.

E.   Metabolic disorders and metabolic liver diseases with cirrhosis (not an all-inclusive list):

                                                  i.    Alpha 1-antitrypsin deficiency

                                                ii.    Hemochromatosis

                                               iii.    Inborn errors of metabolism

                                               iv.    Protoporphyria

                                                v.    Wilson`s disease.

F.    Miscellaneous:

                                                  i.    Polycystic disease of the liver.

                                                ii.    Familial amyloid polyneuropathy.

                                               iii.    Trauma.

                                               iv.    Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen (Tylenol) overdose, etc.).

                                                v.    Portopulmonary 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.

                                               vi.    Hepatopulmonary syndrome when the following selection criteria are met:

1.    Chronic liver disease with non-cirrhotic portal hypertension; and

2.    Arterial hypoxemia (PaO2 less than 60 mm Hg or AaO2 gradient greater than 20 mm Hg in supine or standing position); and

3.    Intrapulmonary vascular dilatation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography).

Codes Used In This BI:

1. Requests for liver transplantation for adolescents and adults with a MELD score of 10 or less who have not been approved by the UNOS Regional Review Board are not covered.

2.    Retransplantation:
QualChoice considers retransplantation following a failed liver transplant medically necessary if the initial transplant was performed for a covered indication.

3.    Contraindications:
QualChoice considers liver transplantation to be non covered for members with any of the following absolute contraindications to liver transplantation:

1. Use of alcohol within the last six (6) months
2. Use of illicit drugs within the last six (6) months
3. Abuse of any substances within the last six (6) months
4. Active sepsis outside the biliary tract
5. Presence of significant organ system failure other than kidney, liver or small bowel
6. Other effective medical treatments or surgical options are available.

4.    Experimental and Investigational Procedures:
QualChoice considers the following indications/procedures regarding liver transplantation experimental and investigational:

1. Malignancies other than those listed as covered above
2. Ectopic or auxiliary liver transplantation
3. Xenotransplantation
4. Hepatocellular transplantation

e.    Bioartificial liver transplantation.

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