47140
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
57.92
Facility
$3345.10
Non-Facility
$3345.10
Documentation Required
- Evidence of risk-reduction behaviors for substance use when claiming exemption from exclusion.
- Serial blood and urine testing may be used to verify abstinence from substances of concern.
- If urgent transplant timelines, documentation of the patient's commitment to reduce/cease substance use.
- Multidisciplinary pre-transplant evaluation documenting clinical necessity and assessment of psychosocial, neurocognitive, and developmental needs.
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
7 Active Policies
AMBETTER-CP.MP.120 — Pediatric Liver Transplant
ANTHEM-MP-A053525 — TRANS.00008 Liver Transplantation
BCBSIL-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
BCBSMT-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
BCBSNM-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
Related Codes
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