47144
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documented measurement of renal function (GFR/eGFR) to confirm ≥40 mL/min/1.73 m² or justification for multi-organ transplant
- Documentation of cancer status demonstrating no high risk of recurrence or mortality from malignancy
- HIV laboratory documentation (viral load) and evidence that required HIV-specific transplant criteria are met when applicable
- Clinical records documenting frequency and cause of hospitalizations related to intestinal failure
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
9 Active Policies
AMBETTER-CP.MP.58 — Intestinal and Multivisceral Transplant
AMBETTER-CP.MP.120 — Pediatric Liver Transplant
ANTHEM-MP-A053525 — TRANS.00008 Liver Transplantation
ANTHEM-MP-A053824 — TRANS.00013 Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
BCBSIL-SUR703.009 — Small Bowel/Liver and Multivisceral Transplant
Related Codes
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