TRANS.00008 Liver Transplantation

This policy addresses liver transplantation (whole or partial) using deceased or living donors. It is covered as medically necessary for selected individuals with end-stage liver failure due to irreversible liver damage who meet disease-specific and general selection criteria, including cholestatic liver diseases (e.g., primary biliary cirrhosis, primary sclerosing cholangitis), biliary atresia, Caroli’s disease, familial cholestasis, Alagille’s disease, and cystic fibrosis. It is not covered (investigational/experimental) for extrahepatic malignancy, for intrahepatic cholangiocarcinoma or hepatocellular carcinoma that extends beyond the liver, for conditions not leading to irreversible end-stage liver failure, or for xenotransplantation and bioartificial liver devices; multi-organ transplants require criteria to be met for each organ.

"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."