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National Coverage Determination (NCD)

Adult Liver Transplantation

260.1

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Tracking Information

Publication Number
100-3
Manual Section Number
260.1
Manual Section Title
Adult Liver Transplantation
Version Number
2
Effective Date of this Version
06/19/2006
Ending Effective Date of this Version
06/21/2012
Implementation Date
06/19/2006
Implementation QR Modifier Date

Description Information

Benefit Category
Inpatient Hospital Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

CIM 35-53

A. General

Effective July 15, 1996, adult liver transplantation when performed on beneficiaries with end stage liver disease other than hepatitis B or malignancies is covered under Medicare when performed in a facility which is approved by CMS as meeting institutional coverage criteria.

Effective December 10, 1999, adult liver transplantation when performed on beneficiaries with end stage liver disease other than malignancies is covered under Medicare when performed in a facility which is approved by CMS as meeting institutional coverage criteria.

Effective September 1, 2001, Medicare covers adult liver transplantation for hepatocellular carcinoma when the following conditions are met:

  • The patient is not a candidate for subtotal liver resection;
  • The patient's tumor(s) is less than or equal to 5 cm in diameter;
  • There is no macrovascular involvement;
  • There is no identifiable extrahepatic spread of tumor to surrounding lymph nodes, lungs, abdominal organs or bone; and
  • The transplant is furnished in a facility that is approved by CMS as meeting institutional coverage criteria for liver transplants (See 65 FR 15006).

Adult liver transplantation for other malignancies remains excluded from coverage. Coverage of adult liver transplantation is effective as of the date of the facility's approval, but for applications received before July 13, 1991, can be effective as early as March 8, 1990. (See "Federal Register" 56 FR 15006 dated April 12, 1991.)

B. Follow-up Care

Follow-up care or retransplantation required as a result of a covered liver transplant is covered, provided such services are otherwise reasonable and necessary. Follow-up care is also covered for patients who have been discharged from a hospital after receiving noncoverd liver transplant. Coverage for follow-up care is for items and services that are reasonable and necessary as determined by Medicare guidelines.

C. Immunosuppressive Drugs

See the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," §50.5.1 and the Medicare Claims Processing Manual, Chapter 17, "Drugs and Biologicals," §80.3.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
48
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R48NCD.pdf
Revision History

03/2006 - Delete coding information. Effective/Implementation date 06/19/2006. (TN 48) (CR4278)

07/17/2001 - Revised to provide coverage for patients with hepatocellular carcinoma under certain circumstances. Liver transplantation for other forms of malignancies remains noncovered.  Effective and implementation dates 09/01/2001. (TN 142) (CR 1738)

12/1999 - Revised to remove hepatitis B as a noncovered condition. Effective date 12/10/1999 and implementation date 01/17/2000. (TN 121) (CR 1071)

06/1996 - Revised to expand coverage to all ESLD diagnoses except hepatitis B or malignancies. Effective 07/15/1996. (TN 87)

08/1992 - Revised to add ICD-9-CM codes not included in previous revision. Effective date NA. (TN 60)

1991 - Renamed and revised to extend coverage to adults with specific conditions. Effective date 03/08/1990. (TN 52)
Other

National Coverage Analyses (NCAs)

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Adult Liver Transplantation 3 06/21/2012 - N/A View
Adult Liver Transplantation 2 06/19/2006 - 06/21/2012 You are here
Adult Liver Transplantation 1 09/01/2001 - 06/19/2006 View
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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