91200
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.20
Facility
$33.73
Non-Facility
$33.73
Documentation Required
- For DGUOK deficiency, documentation of neurological status is required to determine transplant benefit: "Long-term survival is best predicted by the absence of profound hypotonia, significant psychomotor retardation, or nystagmus. ... liver transplantation appears to be futile in the presence of specific neurological signs or symptoms in patients affected with DGUOK deficiency."
- OrganOx metra device donor/organ criteria should be documented: donor type (DBD vs DCD), donor age (<= 40 years for DCD), functional warm ischemic time (<= 20 minutes), and macro-steatosis (<=15%): "It is suitable for liver grafts from donors after brain death (DBD), or liver grafts from donors after circulatory death (DCD) of less than or equal to 40 years of age, with less than or equal to 20 mins of functional warm ischemic time ..., and macro-steatosis of less than or equal to 15 %."
- For candidate selection and prognostication in HCC, pre-transplant inflammatory markers (pre-transplant neutrophil-to-lymphocyte ratio or platelet-to-lymphocyte ratio) have prognostic associations and may be documented: "Elevated pre-transplant NLR had a close association with the overall survival ..." and "high PLR value was associated with a significant increase in recurrence after transplantation."
Key Coverage Criteria
- CPT codes covered if selection criteria are met: 47135 Liver allotransplantation; orthotopic; partial or whole, from cadaver or living donor, any age
- Retransplantation following a failed liver transplant when the initial transplant was performed for a covered indication.
- ICD-10 codes covered if selection criteria are met: E83.10, E83.19 Other and unspecified disorders of iron metabolism
- ICD-10 codes covered if selection criteria are met: E83.110 - E83.119 Hereditary hemochromatosis
- ICD-10 codes covered if selection criteria are met: E85.1 Neuropathic heredofamilial amyloidosis
- Large, unresectable fibrolamellar hepatocellular carcinomas (HCCs).
2 Active Policies
AETNA-CPB-0596 — Liver Transplantation
AETNA-CPB-0690 — Noninvasive Tests for Hepatic Fibrosis
Related Codes
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