47134
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Autoimmune hepatitis
- Toxin exposure: Amanita mushroom poisoning
- Note: Members must meet the disease specific criteria as well as the general Individual Selection Criteria below for the transplantation to be considered medically necessary.
- Medically Necessary:A whole or partial liver transplant using a deceased or living donor is consideredmedically necessaryfor selected individuals with end-stage organ failure due to irreversible liver damage that includes, but is not limited to, the following conditions:
- Cholestatic liver diseases:Primary biliary cirrhosisPrimary sclerosing cholangitisBiliary atresiaCaroli's diseaseFamilial cholestasisArteriohepatic dysplasia (Alagaille's disease)Cystic Fibrosis
- Primary biliary cirrhosis
1 Active Policy
ANTHEM-MP-A053525 — TRANS.00008 Liver Transplantation
Related Codes
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