Medical Policy

D-1259-001

Policy Id

HHO-DE-MP-1259

Topic

Transplants

Section

Archived Policies

Effective Date

Jun 16, 2025

Issued Date

May 16, 2025

Last Revision Date

05/2025

THIS IS NO LONGER AN ACTIVE POLICY. POLICY WAS ARCHIVED ON 06/16/2025.

DISCLAIMER

Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation. 

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations. 

CPT Code Description

50320

Donor Nephrectomy (including cold preservation); open, from living donor.

50340

Recipient Nephrectomy (separate procedure).

50360

Renal Allotransplantation, implantation of graft; without recipient nephrectomy.

50365

Renal Allotransplantation, implantation of graft; with recipient nephrectomy.

50370

Removal of transplanted renal allograft.

50380

Renal autotransplantation, reimplantation of kidney.

50547

Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor.

Diagnosis Code                              
N18.4 N18.5                    N18.6

 

Corneal Transplant

Prior authorization is required.

Corneal transplant may be considered medically necessary for ANY of the following indications:

  • Aphakic corneal edema; or
  • Chemical injuries; or
  • Congenital opacities; or
  • Corneal degenerations; or
  • Ectasias/thinnings; or
  • Microbial/post-microbial keratitis; or
  • Noninfectious ulcerative keratitis or
  • Perforation; or
  • Primary corneal endotheliopathies; or
  • Pseudophakic corneal edema; or
  • Regraft related to allograft rejection; or
  • Regraft unrelated to allograft rejection; or
  • Steven-Johnson Syndrome; or
  • Stromal corneal dystrophies; or
  • Trauma or injuries that cause corneal scarring; or
  • Viral/post-viral keratitis

Corneal transplants not meeting the criteria as indicated in this policy is considered not medically necessary.

Artificial Cornea

Keratoprosthesis using a United States Food and Drug Administration (U.S. FDA) approved device may be considered medically necessary when ALL the following criteria are met:

  • Cadaveric corneal transplants have failed or there is a very low likelihood of success; and
  • The cornea is severely opaque and vascularized.

The use of an artificial cornea device not meeting the criteria as indicated in this policy is considered not medically necessary.

Endothelial Keratoplasty (DSEK, DSAEK, DMEK, DMAEK)

Endothelial keratoplasty (Descemet stripping endothelial keratoplasty [DSEK]), Descemet stripping automated endothelial keratoplasty (DSAEK), Descemet membrane endothelial keratoplasty (DMEK), or Descemet membrane automated endothelial keratoplasty (DMAEK) may be considered medically necessary for the treatment of endothelial dysfunction, including but not limited to ANY of the following indications:

  • Ruptures in Descemet membrane; or
  • Endothelial dystrophy; or
  • Aphakic, and pseudophakic bullous keratopathy; or
  • Iridocorneal endothelial (ICE) syndrome; or
  • Corneal edema attributed to endothelial failure; and
  • Failure or rejection of a previous corneal transplant. 

Endothelial keratoplasty for any indication other than listed above is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this services cannot be established by the available peer-reviewed literature.

Femtosecond Laser-Assisted Corneal Endothelial Keratoplasty (FLEK)

FLEK or femtosecond and excimer laser assisted endothelial keratoplasty (FELEK) are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this services cannot be established by the available peer-reviewed literature.

Place of Service: Inpatient/Outpatient

   CPT Code        Description              

65710

Keratoplasty (corneal transplant); anterior lamellar

65730

Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)

65750

Keratoplasty (corneal transplant); penetrating (in aphakia)

65755

Keratoplasty (corneal transplant); penetrating (in pseudophakia)

65770

Keratoprosthesis

L8609

Artificial cornea

65756

Keratoplasty (corneal transplant); endothelial

65757

Backbench preparation of corneal endothelial allograft prior to transplantation (list separately in addition to code for primary procedure)

 

Covered Diagnosis Codes for Procedure Codes 65710, 65730, 65750, 65755, 65770, 65756, 65757, and L8609

B60.13

H16.001

H16.002

H16.003

H16.009

H16.011

H16.012

H16.013

H16.021

H16.022

H16.023

H16.031

H16.032

H16.033

H16.041

H16.042

H16.043

H16.051

H16.052

H16.053

H16.061

H16.062

H16.063

H16.071

H16.072

H16.073

H16.101

H16.102

H16.103

H16.111

H16.112

H16.113

H16.121

H16.122

H16.123

H16.131

H16.132

H16.133

H16.141

H16.142

H16.143

H16.201

H16.202

H16.203

H16.211

H16.212

H16.213

H16.221

H16.222

H16.223

H16.231

H16.232

H16.233

H16.251

H16.252

H16.253

H16.261

H16.262

H16.263

H16.291

H16.292

H16.293

H16.301

H16.302

H16.303

H16.311

H16.312

H16.313

H16.321

H16.322

H16.323

H16.331

H16.332

H16.333

H16.391

H16.392

H16.393

H16.401

H16.402

H16.403

H16.411

H16.412

H16.413

H16.421

H16.422

H16.423

H16.431

H16.432

H16.433

H16.441

H16.442

H16.443

H16.8

H16.9

H17.01

H17.02

H17.03

H17.11

H17.12

H17.13

H17.811

H17.812

H17.813

H17.821

H17.822

H17.823

H17.89

H17.9

H18.001

H18.002

H18.003

H18.011

H18.012

H18.013

H18.021

H18.022

H18.023

H18.031

H18.032

H18.033

H18.051

H18.052

H18.053

H18.061

H18.062

H18.063

H18.11

H18.12

H18.13

H18.20

H18.211

H18.212

H18.213

H18.221

H18.222

H18.223

H18.231

H18.232

H18.233

H18.30

H18.311

H18.312

H18.313

H18.321

H18.322

H18.323

H18.331

H18.332

H18.333

H18.40

H18.411

H18.412

H18.413

H18.421

H18.422

H18.423

H18.43

H18.441

H18.442

H18.443

H18.451

H18.452

H18.453

H18.461

H18.462

H18.463

H18.49

H18.503

H18.509

H18.511

H18.512

H18.513

H18.519

H18.521

H18.522

H18.523

H18.529

H18.531

H18.532

H18.533

H18.539

H18.541

H18.542

H18.543

H18.549

H18.551

H18.552

H18.553

H18.559

H18.591

H18.592

H18.593

H18.599

H18.601

H18.602

H18.603

H18.611

H18.612

H18.613

H18.621

H18.622

H18.623

H18.70

H18.711

H18.712

H18.713

H18.721

H18.722

H18.723

H18.731

H18.732

H18.733

H18.791

H18.792

H18.793

H18.811

H18.812

H18.813

H18.821

H18.822

H18.823

H18.831

H18.832

H18.833

H18.891

H18.892

H18.893

H18.9

H54.0X33

H54.0X34

H54.0X35

H54.0X43

H54.0X44

H54.0X45

H54.0X53

H54.0X54

H54.0X55

H54.1131

H54.1132

H54.1141

H54.1142

H54.1151

H54.1152

H54.1213

H54.1214

H54.1215

H54.1223

H54.1224

H54.1225

H54.2X11

H54.2X12

H54.2X21

H54.2X22

H54.3

H54.413A

H54.414A

H54.415A

H54.42A3

H54.42A4

H54.42A5

H54.511A

H54.512A

H54.52A1

H54.52A2

H54.7

H54.8

H55.82

L51.1

Q12.0

Q12.1

Q12.2

Q12.3

Q12.4

Q12.8

Q12.9

S05.21XA

S05.22XA

S05.31XA

S05.32XA

S05.51XA

S05.52XA

S05.60XA

S05.61XA

S05.62XA

S05.70XA

S05.71XA

S05.72XA

S05.8X1A

S05.8X2A

S05.8X9A

S05.91XA

S05.92XA

T26.11XA

T26.11XD

T26.11XS

T26.12XA

T26.12XD

T26.12XS

T49.4X5A

T49.4X5S

T49.5X5A

T49.5X5S

T85.21XA

T85.22XA

T85.29XA

T85.29XD

T85.29XS

T85.390A

T85.390D

T85.390S

T85.391A

T85.391D

T85.391S

T85.398A

T85.398D

T85.398S

T85.79XA

T85.79XD

T85.79XS

T85.818A

T85.818D

T85.818S

T85.820A

T85.820D

T85.820S

T85.828A

T85.828D

T85.828S

T85.830A

T85.830D

T85.830S

T85.838A

T85.838D

T85.838S

T85.840A

T85.840D

T85.840S

T85.848A

T85.848D

T85.848S

T85.850A

T85.850D

T85.850S

T85.858A

T85.858D

T85.858S

T85.860A

T85.860D

T85.860S

T85.868A

T85.868D

T85.868S

T85.890A

T85.890D

T85.890S

T85.898A

T85.898D

T85.898S

T86.8401

T86.8402

T86.8403

T86.8409

T86.8411

T86.8412

T86.8413

T86.8419

T86.8421

T86.8422

T86.8423

T86.8429

T86.8481

T86.8482

T86.8483

T86.8489

T86.8491

T86.8492

T86.8493

T86.8499

 

Heart/Lung

Prior authorization is required.

Heart/lung transplantation may be considered medically necessary for carefully selected individuals with end-stage cardiac and pulmonary disease including, but not limited to ONE of the following diagnoses:

·         Irreversible primary pulmonary hypertension with severe heart failure; or

·         Nonspecific severe pulmonary fibrosis, with severe heart failure; or

·         Eisenmenger complex with irreversible pulmonary hypertension and severe heart failure associated with congenital heart disease that is unable to be surgically repaired; or

·         Cystic fibrosis with severe heart failure; or

·         Chronic obstructive pulmonary disease with heart failure; or

·         Emphysema with severe heart failure; or

·         Pulmonary fibrosis with uncontrollable pulmonary hypertension or heart failure.

 

In both adult and pediatric individuals, isolated cardiac or pulmonary transplantations are preferred to combined heart/lung transplantation when medical or surgical management-other than organ transplantation-is available.

Note: In all the above, heart failure must be severe enough that it is unlikely to recover after lung-only transplantation.

Heart/lung retransplantation after a failed primary heart/lung transplant may be considered medically necessary in individuals who meet criteria for heart/lung transplantation.

Heart/lung transplantation or retransplantation not meeting the criteria as indicated in this policy is considered not medically necessary.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient aged 18 or older.

 

General Criteria

The factors below are potential contraindications subject to the judgment of the transplant center:

·         Known current malignancy, including metastatic cancer; or

·         Recent malignancy with high risk of recurrence; or

·         Untreated systemic infection making immunosuppression unsafe, including chronic infection; or

·         Other irreversible end-stage diseases not attributed to heart or lung disease; or

·         History of cancer with a moderate risk of recurrence; or

·         Systemic disease that could be exacerbated by immunosuppression; or

·         Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

·         Human Immunodeficiency virus (HIV) disease unless ALL of the following are noted: 

    • CD4 count greater than 200 cells/mm; and
    • Undetectable HIV-1 ribonucleic acid (RNA) viral load; and
    • 3 or more months of stable anti-retroviral therapy; and
    • Absence of opportunistic infections (eg aspergillus, tuberculosis, coccidiodi, other resistant fungal infections) or neoplasms (eg Kaposi’s sarcoma) associated with HIV disease

 

Heart/Lung-Specific Criteria

When the candidate is eligible to receive a heart in accordance with United Network for Organ Sharing (UNOS) guidelines for cardiac transplantation, the lung(s) shall be allocated to the heart/lung candidate from the same donor. When the candidate is eligible to receive a lung in accordance with the UNOS Lung Allocation System, the heart shall be allocated to the heart/lung candidate from the same donor "after the heart has been offered to all heart and heart-lung potential transplant recipients in allocation classifications 1 through 4." Candidates with allocation classifications 1 through 4 falls within adult status 1 or 2 or pediatric status 1A.

 

Specific criteria for prioritizing donor thoracic organs for transplant are provided by the Organ Procurement and Transplantation Network (OPTN) and implemented through a contract with UNOS. Donor thoracic organs are prioritized by UNOS based on recipient medical urgency, distance from donor hospital, and pediatric status. Individuals who are most severely ill are given highest priority.

 

The following factors are considered in assessing the severity of cardiac illness: reliance on continuous mechanical ventilation, infusion of intravenous inotropes, and/or dependency on mechanical circulatory support (i.e., total artificial heart, intra-aortic balloon pump, extracorporeal membrane oxygenator, ventricular assist device). Factors considered in assessing the severity of pulmonary illness include increased pulmonary artery systolic pressure, pulmonary arterial hypertension, and/or elevated pulmonary vascular resistance.

 

Additional criteria may be considered in pediatric individuals, including diagnosis of an OPTN-approved congenital heart disease diagnosis, presence of ductal dependent pulmonary or systemic circulation, and diagnosis of hypertrophic or restrictive cardiomyopathy while less than 1-year-old. Of note, pediatric heart transplant candidates who remain on the waiting list at the time of their 18th birthday without receiving a transplant continue to qualify for medical urgency status based on the pediatric criteria.

Individuals who are considered temporarily unsuitable to receive a thoracic organ transplant may be assigned an inactive status.

Place of Service: Inpatient

CPT Code           Description                

33935

Heart-lung transplant with recipient cardiectomy-pneumonectomy.

33945

Heart transplant, with or without recipient, cardiectomy

E84.0

E84.8

I09.81                   I11.0               I11.9                   I13.0                   I25.3                  
I25.82 I27.0 I27.20 I27.22 I27.23 I27.24 I27.81
I27.83 I27.89 I27.9 I50.1 I50.20 I50.21 I50.22
I50.23 I50.30 I50.31 I50.32 I50.33    

I50.40

I50.41

I50.42

I50.43

I50.810

I50.811

I50.812

I50.813

I50.814

I50.82

I50.83

I50.84

I50.89

I50.9

J43.0

J43.1

J43.2

J43.8

J43.9

J44.0

J44.1

J44.89

J44.9

J84.10

J84.112

J84.178

J96.10

J96.11

J96.12 J96.20 J96.21 J96.22 J96.90 J96.91 J96.92
J98.09 J98.19 J98.2 J98.4 Q20.6 Q20.8 Q20.9
Q21.8 Q24.4 Q24.5 Q24.6 Q24.8 Q24.9 Q33.0
Q33.3 Q33.4 Q33.6 Q33.8 Q33.9 T86.20 T86.30
T86.31 T86.32 T86.33 T86.39      

 

Liver Transplant

Prior authorization is required.

Liver transplantation is currently the treatment of last resort for individuals with end-stage liver disease. Liver transplantation may be performed with a liver donation after a brain or cardiac death or with a liver segment donation from a living donor. Individuals are prioritized for transplant by mortality risk and severity of illness criteria developed by the Organ Procurement and Transplantation Network (OPTN) and the United Network of Organ Sharing (UNOS). The severity of illness is determined by the Model for End-stage Liver Disease (MELD) and Pediatric End-stage Liver Disease (PELD) scores.

A liver transplant using a cadaver or living donor may be considered medically necessary for carefully selected individuals with end-stage liver failure due to irreversibly damaged livers. Etiologies of end-stage liver disease include, but are not limited to ANY of the following:

·         Hepatocellular Diseases

o    Alcoholic liver disease; or

o    Viral hepatitis (either A, B, C, or non-A, non-B); or

o    Autoimmune hepatitis; or

o    α1-Antitrypsin deficiency; or

o    Hemochromatosis; or

o    Nonalcoholic steatohepatitis; or

o    Protoporphyria; or

o    Wilson disease; or

o    Cholestatic liver diseases

o    Primary biliary cirrhosis; or

o    Primary sclerosing cholangitis with development of secondary biliary cirrhosis; or

o    Biliary atresia; or

·         Vascular disease

o    Budd-Chiari syndrome; or

·         Primary Hepatocellular Carcinoma

·         Inborn Errors of Metabolism

·         Trauma and toxic reactions

·         Miscellaneous

o    Familial amyloid polyneuropathy

 

Liver transplantation may be considered medically necessary in individuals with polycystic disease of the liver who have massive hepatomegaly causing obstruction or functional impairment.

Liver transplantation may be considered medically necessary in individuals with unresectable hilar cholangiocarcinoma.

Liver transplantation may be considered medically necessary in pediatric individuals with nonmetastatic hepatoblastoma as per UNOS and OPTN guidelines.

Liver retransplantation may be considered medically necessary in individuals with ANY of the following:

·         Primary graft nonfunction; or

·         Hepatic artery thrombosis; or

·         Chronic rejection; or

·         Ischemic type biliary lesions after donation after cardiac death; or

·         Recurrent non-neoplastic disease-causing late graft failure.

 

Liver transplantation is experimental and investigational and therefore noncovered because the safety/and/or effectiveness of this service cannot be established by the available published peer-reviewed literature for the following situations:

·         Individuals with intrahepatic cholangiocarcinoma; or

·         Individuals with neuroendocrine tumors metastatic to the liver.

 

Liver transplantation is considered not medically necessary in ANY of the following individuals;

·         Individuals with hepatocellular carcinoma that has extended beyond the liver; or

·         Individuals with ongoing alcohol and/or drug abuse:

o    Note: Evidence for abstinence may vary among liver transplant programs, but generally a minimum of 3 months is required.

 

Liver transplantation not meeting the criteria as indicated in this policy is considered not medically necessary.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

 

Contraindications

Potential contraindications for solid organ transplant are subject to the judgment of the transplant center and may include, but is not limited to, the following:

·         Known current malignancy, including metastatic cancer; or

·         Recent malignancy with high risk of recurrence; or

·         Untreated systemic infection making immunosuppression unsafe, including chronic infection; or

·         Other irreversible end-stage diseases not attributed to liver disease; or

·         History of cancer with a moderate risk of recurrence; or

·         Systemic disease that could be exacerbated by immunosuppression; or

·         Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

 

Liver-specific criteria

The MELD and PELD scores range from 6 (less ill) to 40 (gravely ill). The MELD and PELD scores will change during an individual's tenure on the waiting list.

Individuals with liver disease related to alcohol or drug abuse must be actively involved in a substance abuse treatment program.

Tobacco consumption is a contraindication.

Individuals with polycystic disease of the liver do not develop liver failure but may require transplantation due to the anatomic complications of a hugely enlarged liver. The MELD and PELD score may not apply to these cases. One of the following complications should be present:

·         Enlargement of liver impinging on respiratory function; or

·         Extremely painful enlargement of liver; or

·         Enlargement of liver significantly compressing and interfering with function of other abdominal organs.

 

Individuals with familial amyloid polyneuropathy do not experience liver disease per se, but develop polyneuropathy and cardiac amyloidosis due to the production of a variant transthyretin molecule by the liver. MELD and PELD exception criteria and scores may apply to these cases. Candidacy for liver transplant is an individual consideration based on the morbidity of the polyneuropathy. Many individuals may not be candidates for liver transplant alone due to coexisting cardiac disease; or

 

Hepatocellular Carcinoma

Criteria used for individual selection of hepatocellular carcinoma (HCC) individuals eligible for liver transplant include the Milan criteria, which is considered the criterion standard, the University of California, San Francisco expanded criteria, and United Network of Organ Sharing (UNOS) criteria.

 

Milan Criteria

A single tumor 5 cm or less or 2 to 3 tumors 3 cm or less.

 

University of California, San Francisco Expanded Criteria

A single tumor 6.5 cm or less or up to 3 tumors 4.5 cm or less, and a total tumor size of 8 cm or less.

 

UNOS Stage T2 Criteria

A single tumor 2 cm or greater and up to 5 cm or less or 2 to 3 tumors 1 cm or greater and up to 3 cm or less and without extrahepatic spread or macrovascular invasion.

 

Individuals with HCC are appropriate candidates for liver transplant only if the disease remains confined to the liver. Therefore, the individual should be periodically monitored while on the waiting list, and if metastatic disease develops, the individual should be removed from the transplant waiting list. Also, at the time of transplant, a backup candidate should be scheduled. If locally extensive or metastatic cancer is discovered at the time of exploration before hepatectomy, the transplant should be aborted, and the backup candidate scheduled for transplant.

 

Note that liver transplant for those with T3 HCC is not prohibited by UNOS guidelines, but such individuals do not receive any priority on the waiting list. All individuals with HCC awaiting transplant are reassessed at 3 month intervals. Those whose tumors have progressed and are no longer stage T2 will lose the additional allocation points.

 

Additionally, nodules identified through imaging of cirrhotic livers are given a class 5 designation. Class 5B and 5T nodules are eligible for automatic priority. Class 5B criteria consist of a single nodule 2 cm or larger and up to 5 cm (T2 stage) that meets specified imaging criteria. Class 5T nodules have undergone subsequent locoregional treatment after being automatically approved on initial application or extension. A single class 5A nodule (greater than 1 cm and less than 2 cm) corresponds to T1 HCC and does not qualify for automatic priority. However, combinations of class 5A nodules are eligible for automatic priority if they meet stage T2 criteria. Class 5X lesions are outside of stage T2 and ineligible for automatic exception points. Nodules less than 1 cm are considered indeterminate and are not considered for additional priority. Therefore, the UNOS allocation system. provides strong incentives to use locoregional therapies to downsize tumors to T2 status and to prevent progression while on the waiting list.

 

Cholangiocarcinoma

According to the Organ Procurement and Transplant Network policy on liver allocation, candidates with cholangiocarcinoma meeting the following criteria will be eligible for a MELD or PELD exception with a 10% mortality equivalent increase every 3 months:

·         Centers must submit a written protocol for individual care to the OPTN and UNOS Liver and Intestinal Organ Transplant Committee before requesting a MELD score exception for a             candidate with cholangiocarcinoma. This protocol should include selection criteria, administration of neoadjuvant therapy before transplant, and operative staging to exclude             individuals with regional hepatic lymph node metastases, intrahepatic metastases, and/or extrahepatic disease. The protocol should include data collection as deemed necessary by             the OPTN and UNOS Liver and Intestinal Organ Transplant Committee; or

·         Candidates must satisfy diagnostic criteria for hilar cholangiocarcinoma: malignant-appearing stricture on cholangiography and one of the following: carbohydrate antigen 19-9 100             U/mL, or and biopsy or cytology results demonstrating malignancy, or aneuploidy. The tumor should be considered unresectable on the basis of technical considerations or underlying             liver disease (e.g., primary sclerosing cholangitis); or

·         If cross-sectional imaging studies (computed tomography scan, ultrasound, magnetic resonance imaging) demonstrate a mass, the mass should be 3 cm or less; or

·         Intra- and extrahepatic metastases should be excluded by cross-sectional imaging studies of the chest and abdomen at the time of initial exception and every 3 months before score             increases; or

·         Regional hepatic lymph node involvement and peritoneal metastases should be assessed by operative staging after completion of neoadjuvant therapy and before liver transplant; or             endoscopic ultrasound-guided aspiration of regional hepatic lymph nodes may be advisable to exclude individuals with obvious metastases before neoadjuvant therapy is initiated; or

·         Transperitoneal aspiration or biopsy of the primary tumor (either by endoscopic ultrasound, operative, or percutaneous approaches) should be avoided because of the high risk of             tumor seeding associated with these procedures.

 

Living Donor Criteria

Donor morbidity and mortality are prime concerns in donors undergoing right lobe, left lobe, or left lateral segment donor partial hepatectomy as part of living donor liver transplant. Partial hepatectomy is a technically demanding surgery, the success of which may be related to the availability of an experienced surgical team. The American Society of Transplant Surgeons proposed the following guidelines for living donors (American Society of Transplant Surgeons: Ethics Committee. American Society of Transplant Surgeons' position paper on adult-to-adult living donor liver transplant):

·         They should be healthy individuals who are carefully evaluated and approved by a multidisciplinary team including hepatologists and surgeons to assure that they can tolerate the                 procedure; or

·         They should undergo evaluation to ensure that they fully understand the procedure and associated risks; or

·         They should be of legal age and have sufficient intellectual ability to understand the procedures and give informed consent; or

·         They should be emotionally related to the recipients; or

·         They must be excluded if the donor is felt or known to be coerced; or

·         They need to have the ability and willingness to comply with long-term follow-up.

Place of Service: Inpatient

  CPT Code         Description               

47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age.

 

Covered Diagnosis Codes for Procedure Code 47135

B15.0

B15.9

B16.0

B16.1

B16.2

B16.9

B17.10

B17.11

B17.8

B17.9

B18.0

B18.1

B18.2

B18.8

B18.9

B19.0

B19.10

B19.11

B19.20

B19.21

B19.9

B25.1

B66.1

B66.3

C22.0

C22.1

C22.2

C22.3

C22.4

C22.7

C22.8

C22.9

E70.0

E70.1

E70.20

E70.21

E70.29

E70.30

E70.310

E70.311

E70.318

E70.319

E70.320

E70.321

E70.328

E70.329

E70.330

E70.331

E70.338

E70.339

E70.39

E70.40

E70.41

E70.49

E70.5

E70.9

E71.0

E71.110

E71.111

E71.118

E71.120

E71.121

E71.128

E71.19

E71.2

E71.30

E71.310

E71.311

E71.312

E71.313

E71.314

E71.318

E71.32

E71.39

E71.40

E71.41

E71.42

E71.43

E71.440

E71.448

E71.50

E71.510

E71.511

E71.518

E71.520

E71.521

E71.522

E71.528

E71.529

E71.53

E71.540

E71.541

E71.542

E71.548

E72.00

E72.01

E72.02

E72.03

E72.04

E72.09

E72.10

E72.11

E72.12

E72.19

E72.20

E72.21

E72.22

E72.23

E72.29

E72.3

E72.4

E72.50

E72.51

E72.52

E72.53

E72.59

E72.81

E72.89

E72.9

E74.00

E74.01

E74.02

E74.03

E74.04

E74.09

E74.10

E74.11

E74.12

E74.19

E74.20

E74.21

E74.29

E74.31

E74.39

E74.4

E74.9

E78.0

E78.01

E78.1

E78.2

E78.3

E78.41

E78.49

E78.5

E78.6

E78.70

E78.79

E78.81

E78.89

E78.9

E80.0

E80.1

E80.20

E80.21

E80.29

E83.00

E83.01

E83.09

E83.10

E83.110

E83.111

E83.118

E83.119

E83.19

E85.0

E85.1

E85.2

E85.3

E85.4

E85.81

E85.82

E85.89

E85.9

E88.09

E88.1

E88.2

E88.3

E88.40

E88.41

E88.42

E88.49

E88.89

E88.9

E88.01

G63

I74.8

I82.0

K70.2

K70.30

K70.31

K70.40

K70.41

K70.9

K71.0

K71.10

K71.11

K71.2

K71.3

K71.4

K71.50

K71.51

K71.6

K71.7

K71.8

K71.9

K72.00

K72.01

K72.10

K72.11

K72.90

K72.91

K73.2

K73.9

K74.00

K74.01

K74.02

K74.3

K74.4

K74.5

K74.60

K74.69

K75.2

K75.3

K75.4

K75.81

K76.0

K76.2

K76.3

K76.4

K76.5

K76.7

K76.89

K77

K83.0

K83.1

K83.5

K83.8

Q44.1

Q44.2

Q44.3

Q44.4

Q44.5

Q44.6

Q44.70

Q44.71

Q44.79

S36.112A

S36.112D

S36.112S

S36.113A

S36.113D

S36.113S

S36.114A

S36.114D

S36.114S

S36.115A

S36.115D

S36.115S

S36.116A

S36.116D

S36.116S

S36.118A

S36.118D

S36.118S

S36.119A

S36.119D

S36.119S

T86.40

T86.41

T86.42

T86.43

T86.49

Z52.6

 

Small Bowel Transplant

Prior authorization is required.

A small bowel transplant may be performed as an isolated procedure. Isolated small bowel transplant is commonly performed in individuals with short bowel syndrome.

Multivisceral transplantation/retransplantation may be performed as an intestinal allograft in combination with a liver allograft, either alone or in combination with one or more of the following organs: stomach, duodenum, jejunum, ileum, pancreas, or colon.

A small bowel transplant using cadaveric intestine may be considered medically necessary in adult and pediatric individuals with ALL the following:

·         Intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micro-nutrient balance); and

·         Who have established long-term dependence on total parenteral nutrition; and

·         Who are developing or have developed severe complications due to total parenteral nutrition.

 

A small bowel transplant using a living donor may be considered medically necessary only when a cadaveric intestine is not available for transplantation in an individual who meets the criteria noted above for a cadaveric intestinal transplant.

 

A small bowel re-transplant meeting the criteria indicated in this policy may be considered medically necessary after a failed primary small bowel transplant.

 

A small bowel transplant using cadaveric or living donors not meeting the criteria as indicated in this policy is considered not medically necessary.

 

A small bowel transplant is considered experimental/investigational for adult and pediatric individuals with intestinal failure who can tolerate total parenteral nutrition and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

In addition to the above criteria and subject to the discretion of the transplant center, a Hepatitis C Virus (HCV) positive donor organ maybe considered an acceptable organ option for an HCV negative adult recipient 18 years of age or older.

 

Multivisceral Transplant

Transplants, such as a multi-visceral transplant and a small bowel and liver transplant, may be considered medically necessary for pediatric and adult individuals with ALL the following:

·         Intestinal failure (characterized by loss of absorption and the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance); and

·         Have been managed with long-term total parenteral nutrition; and

·         Have developed evidence of impending end-stage liver failure.

Multi-visceral or a small bowel and liver re-transplant may be considered medically necessary after a failed primary small bowel and liver transplant or multi-visceral transplant.

A multivisceral or small bowel and liver transplant not meeting the criteria as indicated in this policy is considered not medically necessary.

 

General Criteria

Potential contraindications for solid organ transplant subject to the judgment of the transplant center may include the following:

·         Known current malignancy, including metastatic cancer; or

·         Recent malignancy with high risk of recurrence; or

·         Untreated systemic infection making immunosuppression unsafe, including chronic infection; or

·         Other irreversible end-stage diseases not attributed to intestinal failure; or

·         History of cancer with a moderate risk of recurrence; or

·         Systemic disease that could be exacerbated by immunosuppression; or

·         Psychosocial conditions or chemical dependency affecting ability to adhere to therapy.

·         Human Immunodeficiency virus (HIV) disease unless ALL of the following are noted:

  •   CD4 count greater than 200 cells/mm; and
  • Undetectable HIV-1 ribonucleic acid (RNA) viral load; and
  • 3 or more months of stable anti-retroviral therapy ; and
  • Absence of opportunistic infections (eg aspergillus, tuberculosis, coccidiodi, other resistant fungal infections) or neoplasms (eg Kaposi’s sarcoma) associated with HIV disease 

Intestinal failure results from surgical resection, congenital defect, or disease-associated loss of absorption, and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance. Short bowel syndrome is an example of intestinal failure.

Candidates should meet the following criteria:

·         Adequate cardiopulmonary status

·         Documentation of Individuals compliance with medical management.

 

Small Bowel-Specific Criteria

Individuals who are developing or have developed severe complications due to total parenteral nutrition (TPN) include, but are not limited to, the following: multiple and prolonged hospitalizations to treat TPN-related complications (especially repeated episodes of catheter-related sepsis) or the development of progressive liver failure. In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN, thus avoiding the necessity of a multivisceral transplant. In those receiving TPN, liver disease with jaundice (total bilirubin >3 mg/dL) is often associated with development of irreversible, progressive liver disease. The inability to maintain venous access is another reason to consider small bowel transplant in those who are dependent on TPN.

 

Small Bowel/Liver-Specific Criteria

Evidence of intolerance of total parenteral nutrition (TPN) includes, but is not limited to, multiple and prolonged hospitalizations to treat TPN-related complications or the development of progressive but reversible liver failure. In the setting of progressive liver failure, small bowel transplant may be considered a technique to avoid end-stage liver failure related to chronic TPN and would thus avoid the necessity of a multivisceral transplant.

Place of Service: Inpatient

    CPT Code         Description             

44133

Donor enterectomy, open, with preparation and maintenance of allograft; partial, from living donor.

44135

Intestinal allotransplantation; from cadaver donor.

44136

Intestinal allotransplantation; from living donor.

47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any type.

 

Covered Diagnosis Codes

K72.00     K72.01                K72.10                K72.11                  K72.90                      K72.91                   K76.2                
K90.0 K90.1 K90.2 K90.3 K90.49 K90.81 K90.821
K90.822 K90.829 K90.83 K90.89 K90.9 K91.2 T86.851

Policy Sources

American Society of Transplant Surgeons et al-2011

The American Society of Transplant Surgeons, the American Society of Transplantation, the Association of Organ Procurement Organizations, and the United Network for Organ Sharing (2011) issued a joint position statement recommending modifications to the National Organ Transplant Act of 1984. The joint recommendation stated that the potential pool of organs from HIV-infected donors should be explored. With modern antiretroviral therapy, the use of these previously banned organs would open an additional pool of donors to HIV-infected recipients. The increased pool of donors has the potential to shorten waiting times for organs and decrease the number of waiting list deaths. The organs from HIV-infected deceased donors would be used for transplant only with individuals already infected with HIV. In 2013, the HIV Organ Policy Equity Act permitting the use of this group of organ donors.

 

American Academy of Opthalmology-2018

The 2018 Preferred Practice Parameter on ocular edema and opacification by the American Academy of Ophthalmology did not provide specific recommendations on the keratoprosthesis, but discussed the technology and its current use:

“Significant improvements in the design and postoperative management of the Boston type 1 keratoprosthesis has resulted in a steady rise in the number of these procedures performed both in the United States and abroad. Reduced incidence of postoperative stromal necrosis and bacterial endophthalmitis due to the chronic use of protective soft contact lenses and topical antibiotics has resulted in improved retention and visual outcomes and has had a positive impact on surgeons’ perceptions of when to recommend keratoprosthesis. Once considered a procedure of last resort in patients with severe bilateral visual impairment, it is now being used for a variety of unilateral and bilateral indications, such as ocular trauma, herpetic keratitis, aniridia, and Stevens-Johnson syndrome. More recently, as corneal surgeons have gained a greater appreciation of the failure rate of repeat corneal transplantation, a role for a keratoprosthetic in cases of multiple graft failure has become clearer. Despite earlier suggestions, keratoprosthetics are not considered ideal for pediatric cases, particularly as primary treatment.…

“Patients with severe dry eye and autoimmune ocular surface diseases...remain a difficult management group despite the other successes of the Boston type 1 keratoprosthetic. Primary placement of the Boston keratoprosthesis in this group of patients results in a higher rate of epithelial defects, scleral and corneal necrosis, extrusion, and endophthalmitis. Some surgeons advocate ocular surface reconstruction with combined keratolimbal allografts or living related allografts prior to placement of the keratoprosthesis. This can potentially lead to improved outcomes in this group. The Boston type 2 keratoprosthetic designed to be used through the eyelid and the osteo-odonto-keratoprosthesis have been implanted with some success in this group of patients.”

American Academy of Ophthalmology-2009

In 2009, the American Academy of Ophthalmology (AAO) published a position paper on endothelial keratoplasty, stating that the optical advantages, speed of visual rehabilitation, and lower risk of catastrophic wound failure have driven the adoption of endothelial keratoplasty as the standard of care for patients with endothelial failure and otherwise healthy corneas. The 2009 AAO position paper was based in large part on an AAO comprehensive review of the literature on Descemet stripping automated endothelial keratoplasty. AAO concluded that “the evidence reviewed suggests Descemet stripping automated endothelial keratoplasty appears safe and efficacious for the treatment of endothelial diseases of the cornea. Evidence from retrospective and prospective Descemet stripping automated endothelial keratoplasty reports described a variety of complications from the procedure, but these complications do not appear to be permanently sight threatening or detrimental to the ultimate vision recovery in the majority of cases. Long-term data on endothelial cell survival and the risk of late endothelial rejection cannot be determined with this review.” “Descemet stripping automated endothelial keratoplasty should not be used in lieu of penetrating keratoplasty for conditions with concurrent endothelial disease and anterior corneal disease. These situations would include concurrent anterior corneal dystrophies, anterior corneal scars from trauma or prior infection, and ectasia after previous laser vision correction surgery.”

The International Society for Heart and Lung Transplantation-2021

The International Society for Heart and Lung Transplantation updated its consensus-based guidelines on the selection of lung transplant recipients.

These guidelines made the following statements about lung transplantation:

Lung transplantation should be considered for adults with chronic, end-stage lung disease who meet all the following general criteria:

1. High (>50%) risk of death from lung disease within 2 years if lung transplantation is not performed.

2. High (>80%) likelihood of 5-year post-transplant survival from a general medical perspective provided that there is adequate graft function.

Prior to determining that a patient is not a candidate for lung transplantation, referring providers should communicate directly with at least one lung transplant program with experience with the candidate’s potential contraindication(s).

Early referral is recommended to facilitate transplant education for the patient and caregivers, an initial assessment of barriers to transplant, and determination of timing for full evaluation with specific recommendations for optimization of candidacy.

Determination of candidacy requires a detailed evaluation not only to select appropriate candidates, but also to optimize each individual’s status to provide them with the best chance for a successful outcome.

Individual transplant candidacy at a particular institution depends on that center’s expertise for management of patients who have risk factors posing high or substantially increased risk.

Decision making regarding timing of listing for transplant should take into consideration results of the full evaluation, including disease severity and trajectory, estimated wait time for donor organ(s) and survival time without transplant, and candidate’s readiness for transplant.

Just as the decision to list is carefully considered, interval reassessment for continued listing should take place to evaluate the risks and benefits of transplant when considering any changes to the candidate’s status that may impact predicted perioperative or post-transplant outcomes.

When referring for lung transplant evaluation, consider simultaneous referral to palliative care to provide decision support and treatment selection that is consistent with goals of care throughout the transplant evaluation, listing, surgery, and posttransplant.

For combined heart/lung transplant, the guidelines have stated that:

Heart-lung and other multi-organ transplantation should be limited to centers with experience in such procedures and where specialists are available to manage each of the transplanted organs.

Candidates should meet the criteria for lung transplant listing and have significant dysfunction of one or more additional organs or meet the listing criteria for a non-pulmonary organ transplant and have significant pulmonary dysfunction.

Waiting times are likely to be longer and the likelihood of receiving a transplant is reduced when an individual requires more than one organ. Thus, referral should occur earlier in the disease course if multi-organ transplantation may be considered.

American Association for the Study of Liver Diseases et al-2013

The American Association for the Study of Liver Diseases and the American Society of Transplantation (2013) issued joint guidelines on evaluating [individuals] for liver transplant. These guidelines indicated liver transplantation for severe acute or advanced chronic liver disease after all effective medical treatments have been attempted. The formal evaluation should confirm the irreversible nature of the liver disease and lack of effective alternative medical therapy.

The guidelines also stated that liver transplant is indicated for the following conditions:

·         Acute liver failure complications of cirrhosis

·         Liver-based metabolic condition with systemic manifestations

·         Systemic complications of chronic liver disease.

 

The guidelines also included 1-A recommendations (strong recommendation with high-quality evidence) for a liver transplant that:

·         “Tobacco consumption should be prohibited in LT [liver transplant] candidates.”

·         “[Individuals] with HIV infection are candidates for LT if immune function is adequate and the virus is expected to be undetectable by the time of LT.”

·         “LT candidates with HCV [hepatitis C virus] have the same indications for LT as for other etiologies of cirrhosis.”

·         Contraindications to liver transplant included:

o    MELD [Model for End-stage Liver Disease] score less than 15

o    Severe cardiac or pulmonary disease

o    AIDS

o    Ongoing alcohol or illicit substance abuse

o    Hepatocellular carcinoma with metastatic spread

o    Uncontrolled sepsis

o    Anatomic abnormality that precludes liver transplantation

o    Intrahepatic cholangiocarcinoma

o    Extrahepatic malignancy

o    Fulminant hepatic failure

o    Hemangiosarcoma

o    Persistent noncompliance

o    Lack of adequate social support system

 

The American Association for the Study of Liver Diseases, the American Society of Transplantation, and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition issued joint guidelines on the evaluation of the pediatric [individuals] for liver transplant in 2014. The guidelines stated that “disease categories suitable for referral to a pediatric LT program are similar to adults: acute liver failure, autoimmune, cholestasis, metabolic or genetic, oncologic, vascular, and infectious. However, specific etiologies and outcomes differ widely from adult [individuals], justifying independent pediatric guidelines.” The indications listed for liver transplantation included biliary atresia, Alagille syndrome, pediatric acute liver failure, hepatic tumors, HCC, hemangioendothelioma, cystic fibrosis-associated liver disease, urea cycle disorders, immune-mediated liver disease, along with other metabolic or genetic disorders.

 

National Comprehensive Cancer Network-2022

Hepatocellular Carcinoma

The National Comprehensive Cancer Network (NCCN) guidelines on hepatobiliary cancers (v.2.2022) recommend referral to a liver transplant center or bridge therapy for patients with HCC meeting United Network of Organ Sharing criteria of a single tumor measuring 2 to 5 cm, or 2 to 3 tumors 1-3 cm in diameter with no macrovascular involvement or no extrahepatic disease. Patients should be referred to the transplant center before the biopsy. In patients who are ineligible for transplant and in select patients with Child-Pugh class A or B liver function with tumors that are resectable, NCCN indicates resection is the preferred treatment option; locoregional therapy may also be considered. Patients with unresectable HCC should be evaluated for liver transplantation; if the patient is a transplant candidate, then referral to a transplant center should be given or bridge therapy should be considered.

Neuroendocrine and Adrenal Tumors

The NCCN guidelines on neuroendocrine tumors (v.1.2022) indicate that liver transplantation included for neuroendocrine metastases confined to the liver is considered investigational despite “encouraging” 5-year survival rates.

American Gastroenterological Association-2003

The American Gastroenterological Association (2003) produced a medical position statement on short bowel syndrome and intestinal transplantation. It recommended dietary, medical, and surgical solutions. Indications for intestinal transplantation mirrored those of the Centers for Medicare & Medicaid Services. The guidelines acknowledged the limitations of transplant for these individuals. The statement recommended the following Medicare-approved indications, pending availability of additional data:

·         Impending or overt liver failure

·         Thrombosis of major central venous channels

·         Frequent central line-related sepsis

·         Frequent severe dehydration.

 

American Society of Transplantation-2017

The American Society of Transplantation (2017) convened a consensus conference of experts to address issues related to the transplantation of hepatitis C virus (HCV) viremic solid organs into HCV non-viremic recipients.

·         Definition of HCV positive 

  • HCV viremic reflecting a positive NAT should be adopted

·         Data interpretation 

  • HCV antibody status alone limits interpretation of outcomes of transplantation of HCV "positive" organs

·         Transmission and Treatment 

  • Highest risk for unexpected HCV transmission is associated with organ donation from a person who injected drugs within the eclipse or pre-viremic period

·         OPTN policy 

  • No current policies prevent transplantation of HCV-viremic organs into HCV non-viremic recipients

·         Ethical considerations 

  • Transplantation of HCV-viremic organs into HCV non-viremic recipients should be conducted under site specific IRB approved protocols with multi-step informed consent.

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Organ Procurement and Transplantation Network Policies. 2020; https://optn.transplant.hrsa.gov.

 

National Kidney Foundation. Glomerular Filtration Rate (GFR). n.d.; https://www.kidney.org/atoz/content/gfr.

 

American Society of Transplant Surgeons (ASTS), The American Society of Transplantation (AST), The Association of Organ Procurement Organizations (AOPO), et al. Statement on

transplantation of organs from HIV-infected deceased donors.

 

Kervinen, MG, Lehto S, Helve J, et al. Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation. PLoS One. 2018

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Singh A, Zarei-Ghanavati M, Avadhanam V, et al. Systematic review and meta-analysis of clinical outcomes of descemet membrane endothelial keratoplasty versus descemet stripping endothelial keratoplasty/descemet stripping automated endothelial keratoplasty. Cornea. 2017;36(11):1437-1443.

 

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Singhal D, Maharana PK. RE: "Three-year outcome comparison between femtosecond laserassisted and manual descemet membrane endothelial keratoplasty". Cornea. 2019;38(11).

 

Hosny MH, Marrie A, Karim Sidky M, et al. Results of femtosecond laser-assisted descemet stripping automated endothelial keratoplasty. J Ophthalmol. 2017; 2017:8984367.

 

Dunker SL, Dickman MM, Wisse RPL, et al. Descemet membrane endothelial keratoplasty versus ultrathin descemet stripping automated endothelial keratoplasty: A multicenter randomized controlled clinical trial. Ophthalmology. 2020;127(9):1152-1159.

 

Wu J, Wu T, Li J, Wang L, Huang Y. DSAEK or DMEK for failed penetrating keratoplasty: A systematic review and single-arm meta-analysis. Int Ophthalmol. 2021;41(7):2315-2328.

 

Liu Y, Li X, Li W, Jiu X, Tian M. Systematic review and meta-analysis of femtosecond laserenabled keratoplasty versus conventional penetrating keratoplasty. Eur J Ophthalmol. 2021;31(3):976-987.

 

Hjortshøj CS, Gilljam T, Dellgren G, et al. Outcome after heart–lung or lung transplantation in patients with Eisenmenger syndrome. Heart. Published Online First: 21 August 2019

 

Woolley, A. E., Singh, S. K., Goldberg, et al. Heart and lung transplants from HCV-infected donors to uninfected recipients. N Engl J Med. 2019;17:1606-1617.

 

Rudasill, S. E., Lyengar, A., Kwon, O. J., et al. Recipient working status is independently associated with outcomes in heart and lung transplantation. Clin Transplant. 2019;13462

 

United Network for Organ Sharing (UNOS). Heart/Lung: Submitting LAS exception requests for candidates diagnosed with PH. 2018.

 

Organ Procurement and Transplantation Network (OPTN). Organ Procurement and Transplantation Network Policies. Policy 6: Heart and heart-lungs, 2023;

https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Updated September 28, 2023 Accessed October 11, 2023

 

Sertic F, Han J, Diagne D, et al. Not all septal defects are equal: Outcomes of bilateral lung transplant with cardiac defect repair vs combined heart-lung transplant in patients with Eisenmenger syndrome in the United States. Chest. Nov 2020; 158(5): 2097-2106.

 

Riggs KW, Chapman JL, Schecter M, et al. Pediatric heart-lung transplantation: A contemporary analysis of outcomes. Pediatr Transplant. May 2020; 24(3): e13682.

 

Koval CE, Farr M, Krisl J, et al. Heart or lung transplant outcomes in HIV-infected recipients. J

 

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Leard LE, Holm AM, Valapour M, et al. Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. Nov 2021; 40(11): 1349-1379.

 

Singh TP, Cherikh WS, Hsich E et al. The International thoracic organ transplant registry of the international society for heart and lung transplantation: Twenty-fifth pediatric heart transplantation report—2022; focus on infant heart transplantation. J Heart Lung Transplant.2022; 41(10): 1357–1365.

 

Doberne JW, Jawitz OK, Raman V, et al. Heart transplantation survival outcomes of HIV positive and negative recipients. Ann Thorac Surg. 2021; 111(5):1465-1471.

 

InterQual® Level of Care Criteria 2021. Acute Care Adult. McKesson Health Solutions, LLC.

 

National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Hepatobiliary cancers. Version 2.2022.

 

Marot A, Dubois M, TreÂpo E, Moreno C, Deltenre P. Liver transplantation for alcoholic hepatitis: A systematic review with meta-analysis. PLoS ONE. 2018;13(1).

 

Utako P, Emyoo T, Anothaisintawee T, et al. Clinical outcomes after liver transplantation for hepatorenal syndrome: A systematic review and meta-analysis. BioMed Research Intl. 2018.

 

Hamilton EC, Balogh J, Nguyen DT, et al. Liver transplantation for primary hepatic malignancies of childhood: The UNOS experience. J Pediatric Surg. 2018;53(1):163-169.

 

Firl DJ, Kimura S, McVey J, et al. Reframing the approach to patients with hepatocellular carcinoma: Longitudinal assessment with HALTHCC improves ablate and wait strategy. Hepatology. 2018.

 

Yadav DK, Chen W, Bai X, et al. Salvage liver transplant versus primary liver transplant for patients with hepatocellular carcinoma. Ann Transplant. 2018;3;23:524-545.

 

National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: Neuroendocrine and Adrenal Tumors. Version 1.2022.

 

Luckett K, Kaiser TE, Bari K, et al. Use of hepatitis c virus antibody-positive donor livers in hepatitis Cnonviremic liver transplant recipients. J Am Coll Surg. 2019;228(4):560-567.

 

Saberi B, Hamilton JP, Durand CM, et al. Utilization of hepatitis C virus RNA-positive donor liver for transplant to hepatitis C virus RNA-negative recipient. Liver Transpl. 2018;24(1):140-143.

 

Campos-Varela I, Agudelo EZ, Sarkar M, et al. Use of a hepatitis C virus (HCV) RNA-positive donor in a treated HCV RNA-negative liver transplant recipient. Transpl Infect Dis. 2018;20(1).

 

Kwong AJ, Wall A, Melcher M, et al. Liver transplantation for hepatitis C virus (HCV) non-viremic recipients with HCV viremic donors. Am J Transplant. 2019;19(5):1380-1387.

 

Organ Procurement and Transplantation Network. Governance. Policies. Policy 9: Allocation of livers and liver-intestines. 04/01/2020.

 

American Association for the Study of Liver Diseases, American Society of Transplantation. Liver transplantation, evaluation of the adult patient. 2013; https://www.aasld.org/publications/practiceguidelines.

 

Black CK, Termanini KM, Aguirre O, et al. Solid organ transplantation in the 21 st century. Ann Transl

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Gadiparthi C, Cholankeril G, Perumpail BJ, et al. Use of direct-acting antiviral agents in hepatitis C virus-infected liver transplant candidates. World J Gastroenterol. 2018;24(3):315-322.

 

Blumberg EA, Rogers CC. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33(9):e13499.

 

American Association for the Study of Liver Diseases. Diagnosis and treatment of alcohol associated liver diseases: 2019 Practice Guidance from the American Association for the Study of Liver Diseases. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.30866.

 

Yong JN, Lim WH, Ng CH, et al. Outcomes of nonalcoholic steatohepatitis after liver transplantation: an updated meta-analysis and systematic review [published online ahead of print, 2021]. Clin Gastroenterol Hepatol. 2021;S1542-3565(21)01226-X.

 

Cambridge WA, Fairfield C, Powell JJ, et al. Meta-analysis and meta-regression of survival after liver transplantation for unresectable perihilar cholangiocarcinoma. Ann Surg. 2021;273(2):240-250.

 

Ziogas IA, Giannis D, Economopoulos KP, et al. Liver transplantation for intrahepatic cholangiocarcinoma: A meta-analysis and meta-regression of survival rates. Transplantation. 2021;105(10):2263-2271.

 

Hue JJ, Rocha FG, Ammori JB, et al. A comparison of surgical resection and liver transplantation in the treatment of intrahepatic cholangiocarcinoma in the era of modern chemotherapy: An analysis of the National Cancer Database. J Surg Oncol. 2021;123(4):949-956.

 

Salimi J, Jafarian A, Fakhar N, et al. Study of re-transplantation and prognosis in liver transplant center in Iran. Gastroenterol Hepatol Bed Bench. 2021;14(3):237-242.

 

Bouari S, Rijkse E, Metselaar HJ, et al. A comparison between combined liver kidney transplants to liver transplants alone: A systematic review and meta-analysis. Transplant Rev (Orlando). 2021;35(4):100633.

 

Tang W, Qiu JG, Cai Y, Cheng L, Du CY. Increased surgical complications but improved overall survival with adult living donor compared to deceased donor liver transplantation: A systematic review and meta-analysis. Biomed Res Int. 2020;2020:1320830.

 

Kapila N, Menon KVN, Al-Khalloufi K, et al. Hepatitis C virus NAT-positive solid organ allografts transplanted into hepatitis C virus-negative recipients: A real-world experience. Hepatology. 2020;72(1):32-41.

 

Cotter TG, Paul S, Sandıkçı B, et al. Increasing utilization and excellent initial outcomes following liver transplant of hepatitis C virus (HCV)-viremic donors into HCV-negative recipients: Outcomes following liver transplant of HCV-viremic donors. Hepatology. 2019;69(6):2381-2395.

 

Sobotka LA, Mumtaz K, Wellner MR, et al. Outcomes of hepatitis C virus seropositive donors to hepatitis C virus seronegative liver recipients: A large single center analysis. Ann Hepatol. 2021;24:100318.

 

Aqel B, Wijarnpreecha K, Pungpapong S, et al. Outcomes following liver transplantation from HCVseropositive donors to HCV-seronegative recipients. J Hepatol. 2021;74(4):873-880.

 

Lacaille F, Irtan S, Dupic L, Talbotec C, Lesage F, et al. Twenty-eight years of intestinal transplantation in Paris: Experience of the oldest European center. Transpl Int. 2017;30(2):178186.

 

Ekser B, Kubal CA, Fridell JA, Mangus RS. Comparable outcomes in intestinal retransplantation: Single-center cohort study. Clin Transplant. 2018;32(7):e13290.

 

Organ Procurement and Transplantation Network (OPTN). Organ Procurement and Transplantation Network Policies. 2022.

 

Levitsky J, Formica RN, Bloom RD, et al. The American Society of Transplantation consensus conference on the use of Hepatitis C viremic donors in solid organ transplantation. Am J Transplant. 2017;17:2790-2802.

 

Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf). 2017;5(1):20-28.

 

Loo L, Vrakas G, Reddy S, et al. Intestinal transplantation: A review. Curr Opin Gastroenterol. 2017;33(3):203-211.

 

Garcia Aroz S, Tzvetanov I, Hetterman EA, et al. Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience. Pediatr Transplant. 2017;21(4).

 

Luckett k, Kaiser TE, Bari K, et al. Use of hepatitis C virus antibody-positive donor livers in hepatitis C nonviremic liver transplant recipients. J AM Coll Surg. 2019:228(4):560-567.

 

Saberi B, Hamilton JP, Durand CM, et al. Utilization of hepatitis C virus RNA-positive donor liver for transplant to hepatitis C virus RNA-negative recipient. Liver Transpl. 2018;24(1):140-143.

 

Campos-Varela I, Agudelo EZ, Sarkar M, et al. Use of hepatitis C virus (HCV) RNA-positive donor in a treated HCV RNA-negative liver transplant recipient. Transpl Infect Dis. 2018;20(1).

 

Kwong AJ, Wall A, Melcher M, et al. Liver transplantation for hepatitis C virus (HCV) non-viremic recipients with HCV viremic donors. Am J Transplant. 2019;19(5):1380-1387.

 

InterQual® Level of Care Criteria 2021. Acute Care Adult. Change Healthcare, LLC.

 

Raghu VK, Beaumont JL, Everly MJ, Venick RS, Lacaille F, Mazariegos GV. Pediatric intestinal transplantation: Analysis of the intestinal transplant registry. Pediatr Transplant. 2019;23(8): e13580.

 

Spence AB, Natarajan M, Fogleman S, Biswas R, Girlanda R, Timpone J. Intra-abdominal infections among adult intestinal and multivisceral transplant recipients in the 2-year postoperative period. Transpl Infect Dis. 2020;22(1):e13219.

 

Massironi S, Cavalcoli F, Rausa E, Invernizzi P, Braga M, Vecchi M. Understanding short bowel syndrome: Current status and future perspectives. Dig Liver Dis. 2020;52(3):253-261.

 

Bharadwaj S, Tandon P, Gohel TD, et al. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf). 2017;5(1):20-28.

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