Aetna · Clinical coverage policy

Aetna Liver Transplantation coverage criteria

Aetna CPB 0596 covers orthotopic liver transplantation (cadaveric, reduced-size, living-related, or split-liver) as medically necessary for end-stage liver disease from a defined list of cholestatic, hepatocellular, vascular, metabolic, miscellaneous, and select malignant conditions, but only when the patient also clears the eligibility gate (MELD greater than 10, UNOS Regional Review Board approval, or the transplant institution's selection criteria; children under 12 must meet institutional criteria). Retransplantation is covered if the original transplant was for a covered indication, and living-donor compatibility testing is covered. Transplantation is not medically necessary in the presence of listed absolute contraindications (e.g., active sepsis outside the biliary tract, non-liver/kidney/small-bowel organ failure, active substance abuse unless 3 months of documented stability), and a long list of adjunct tests, perfusion systems, biomarkers, drugs, and alternative transplant techniques (e.g., machine perfusion, hepatocyte transplantation, MARS for PFIC, xenotransplantation) are considered experimental/investigational and not covered.

Policy CPB 0596 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0596

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0596 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Liver Transplantation (CPT 47133), and what gets it denied?

Path
Aetna CPB 0596 covers orthotopic liver transplantation (cadaveric, reduced-size, living-related, or split-liver) as medically necessary for end-stage liver disease from a defined list of cholestatic, hepatocellular, vascular, metabolic, miscellaneous, and select malignant conditions, but only when the patient also clears the eligibility gate (MELD greater than 10, UNOS Regional Review Board approval, or the transplant institution's selection criteria; children under 12 must meet institutional criteria). Retransplantation is covered if the original transplant was for a covered indication, and living-donor compatibility testing is covered. Transplantation is not medically necessary in the presence of listed absolute contraindications (e.g., active sepsis outside the biliary tract, non-liver/kidney/small-bowel organ failure, active substance abuse unless 3 months of documented stability), and a long list of adjunct tests, perfusion systems, biomarkers, drugs, and alternative transplant techniques (e.g., machine perfusion, hepatocyte transplantation, MARS for PFIC, xenotransplantation) are considered experimental/investigational and not covered. Coverage criteria include: ELIGIBILITY GATE (Section I.A) — Adolescents 12 years or older AND adults qualify with ONE of: MELD score greater than 10; OR approved for transplant by the UNOS Regional Review Board; OR meet the transplant institution's selection criteria.; ELIGIBILITY GATE (Section I.A) — Children less than 12 years of age who meet the transplanting institution's selection criteria.; In the ABSENCE of an institution's selection criteria, requests are subject to medical necessity review for children, and for adolescents/adults with a MELD score of 10 or less who have not been approved by the UNOS Regional Review Board.; Orthotopic liver transplantation (cadaveric, reduced-size, living related, or split liver) is medically necessary for end-stage liver disease (ESLD) due to a covered condition in a member who ALSO meets the Section I.A eligibility gate.; Cholestatic disease — Biliary atresia.; Cholestatic disease — Familial cholestatic syndromes.; Cholestatic disease — Primary biliary cirrhosis.; Cholestatic disease — Primary sclerosing cholangitis with development of secondary biliary cirrhosis.; Hepatocellular disease — Alcoholic cirrhosis.; Hepatocellular disease — Chronic active hepatitis with cirrhosis (hepatitis B or C).; Hepatocellular disease — Cryptogenic cirrhosis.; Hepatocellular disease — Idiopathic autoimmune hepatitis.; Hepatocellular disease — Post-necrotic cirrhosis due to hepatitis B surface antigen negative state.; Malignancy — Primary hepatocellular carcinoma confined to the liver, covered when ALL of: any lung metastases have been shown to be responsive to chemotherapy; AND member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites; AND there is no macrovascular involvement.; Malignancy — Hepatoblastomas in members less than 12 years of age, covered when ALL of: member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lungs, abdominal organs, bone or other sites. (Spread of hepatoblastoma to veins and lymph nodes does NOT disqualify the member.); Malignancy — Epithelioid hemangioendotheliomas.; Malignancy — Intra-hepatic cholangiocarcinomas (i.e., cholangiocarcinomas confined to the liver).; Malignancy — Large, unresectable fibrolamellar HCCs.; Malignancy — Metastatic neuroendocrine tumors (carcinoid tumors, apudomas, gastrinomas, glucagonomas) in persons with severe symptoms and with metastases restricted to the liver, who are unresponsive to adjuvant therapy after aggressive surgical resection including excision of the primary lesion and reduction of hepatic metastases.; Vascular disease — Budd-Chiari syndrome.; Vascular disease — Veno-occlusive disease.; Metabolic disorder / metabolic liver disease with cirrhosis — Alpha 1-antitrypsin deficiency.; Metabolic disorder / metabolic liver disease with cirrhosis — Hemochromatosis.; Metabolic disorder / metabolic liver disease with cirrhosis — Inborn errors of metabolism.; Metabolic disorder / metabolic liver disease with cirrhosis — Protoporphyria.; Metabolic disorder / metabolic liver disease with cirrhosis — Wilson's disease.; Miscellaneous — Familial amyloid polyneuropathy.; Miscellaneous — Polycystic disease of the liver.; Miscellaneous — Porto-pulmonary hypertension (pulmonary hypertension associated with liver disease or portal hypertension) in persons with a mean pulmonary artery pressure by catheterization of less than 35 mm Hg.; Miscellaneous — Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen overdose, etc.).; Miscellaneous — Trauma.; Miscellaneous — Hepato-pulmonary syndrome, covered when ALL of the following selection criteria are met: arterial hypoxemia (PaO2 less than 60 mm Hg OR AaO2 gradient greater than 20 mm Hg in supine or standing position); AND chronic liver disease with non-cirrhotic portal hypertension; AND intrapulmonary vascular dilatation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography).; Retransplantation following a failed liver transplant is medically necessary IF the initial transplant was performed for a covered indication.; Compatibility testing of prospective liver donors is medically necessary for living donor liver transplantation. (Compatibility testing and related services of the prospective live donor, as well as inpatient care of a compatible live donor for the donation procedure, may be covered under the member's medical benefit.). Applies to 8 codes: 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: To override the active-substance-abuse contraindication: supporting documentation (dated within 4 weeks) demonstrating 3 months of stability, from a treating addiction medical professional or psychiatrist.
Trap
Policy exclusions and limitations: CONTRAINDICATION (not medically necessary) — Active sepsis outside the biliary tract.; CONTRAINDICATION (not medically necessary) — Inability to adhere to the regimen necessary to preserve the transplant, including homelessness, active substance abuse (e.g., alcohol, cocaine, crystal meth, heroin, methadone, and/or narcotics, etc.), and/or unstable psychiatric disease/psychosocial problem. EXCEPTION: the active-substance-abuse contraindication is allowed with supporting documentation (within 4 weeks) demonstrating 3 months of stability from a treating addiction medical professional or psychiatrist.; CONTRAINDICATION (not medically necessary) — Other effective medical treatments or surgical options are available.; CONTRAINDICATION (not medically necessary) — Presence of significant organ system failure other than kidney, liver or small bowel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Basiliximab for induction immunosuppression in individuals undergoing liver transplantation (LT).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Bioartificial liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Biomarkers (acid labile nitroso-compounds (NOx), serum amyloid A protein, procalcitonin, peripheral blood T-cell activation, interleukin 2 (IL-2) receptor, guanylate-binding protein-2 mRNA, graft-derived cell-free DNA, pi-glutathione S-transferase, alpha-glutathione S-transferase and serum HLA class I soluble antigens) for diagnosis of acute allograft rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ectopic or auxiliary liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Everolimus to prevent organ rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Factor V Leiden and F2 testing for member scheduled to receive partial liver transplant for primary sclerosing cholangitis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hepatocellular (hepatocyte) transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hypothermic machine perfusion for reduction of the incidences of early allograft dysfunction and biliary complications after LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver elastography and Doppler examination of the portal veins and hepatic arteries for routine yearly surveillance following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for malignancies other than those listed as covered above.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for the treatment of extra-hepatic hilar cholangiocarcinoma.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Measurements of plasma and urinary neutrophil gelatinase-associated lipocalin (NGAL) for predicting acute kidney injury following orthotopic liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Molecular Adsorbent Recirculating System (MARS) for the treatment of progressive familial intrahepatic cholestasis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Normothermic machine perfusion of donor liver.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — OrganOx metra System for transportation and preservation of the liver prior to transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of vasopressin in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of sorafenib in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Scaffold-based transplantation (combination of xeno-organ and cell transplantations) as an alternative for orthotopic LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Testing of high mobility group box protein 1 (HMGB1) gene polymorphisms for prediction of morbidity and mortality after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Transient elastography for diagnosis of acute cellular rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ursodeoxycholic acid (UDCA), adjuvant use to prevent acute cellular rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Xenotransplantation. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0596 — Liver Transplantation

Coverage criteria

  • ELIGIBILITY GATE (Section I.A) — Adolescents 12 years or older AND adults qualify with ONE of: MELD score greater than 10; OR approved for transplant by the UNOS Regional Review Board; OR meet the transplant institution's selection criteria.
  • ELIGIBILITY GATE (Section I.A) — Children less than 12 years of age who meet the transplanting institution's selection criteria.
  • In the ABSENCE of an institution's selection criteria, requests are subject to medical necessity review for children, and for adolescents/adults with a MELD score of 10 or less who have not been approved by the UNOS Regional Review Board.
  • Orthotopic liver transplantation (cadaveric, reduced-size, living related, or split liver) is medically necessary for end-stage liver disease (ESLD) due to a covered condition in a member who ALSO meets the Section I.A eligibility gate.
  • Cholestatic disease — Biliary atresia.
  • Cholestatic disease — Familial cholestatic syndromes.
  • Cholestatic disease — Primary biliary cirrhosis.
  • Cholestatic disease — Primary sclerosing cholangitis with development of secondary biliary cirrhosis.
  • Hepatocellular disease — Alcoholic cirrhosis.
  • Hepatocellular disease — Chronic active hepatitis with cirrhosis (hepatitis B or C).
  • Hepatocellular disease — Cryptogenic cirrhosis.
  • Hepatocellular disease — Idiopathic autoimmune hepatitis.
  • Hepatocellular disease — Post-necrotic cirrhosis due to hepatitis B surface antigen negative state.
  • Malignancy — Primary hepatocellular carcinoma confined to the liver, covered when ALL of: any lung metastases have been shown to be responsive to chemotherapy; AND member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites; AND there is no macrovascular involvement.
  • Malignancy — Hepatoblastomas in members less than 12 years of age, covered when ALL of: member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lungs, abdominal organs, bone or other sites. (Spread of hepatoblastoma to veins and lymph nodes does NOT disqualify the member.)
  • Malignancy — Epithelioid hemangioendotheliomas.
  • Malignancy — Intra-hepatic cholangiocarcinomas (i.e., cholangiocarcinomas confined to the liver).
  • Malignancy — Large, unresectable fibrolamellar HCCs.
  • Malignancy — Metastatic neuroendocrine tumors (carcinoid tumors, apudomas, gastrinomas, glucagonomas) in persons with severe symptoms and with metastases restricted to the liver, who are unresponsive to adjuvant therapy after aggressive surgical resection including excision of the primary lesion and reduction of hepatic metastases.
  • Vascular disease — Budd-Chiari syndrome.
  • Vascular disease — Veno-occlusive disease.
  • Metabolic disorder / metabolic liver disease with cirrhosis — Alpha 1-antitrypsin deficiency.
  • Metabolic disorder / metabolic liver disease with cirrhosis — Hemochromatosis.
  • Metabolic disorder / metabolic liver disease with cirrhosis — Inborn errors of metabolism.
  • Metabolic disorder / metabolic liver disease with cirrhosis — Protoporphyria.
  • Metabolic disorder / metabolic liver disease with cirrhosis — Wilson's disease.
  • Miscellaneous — Familial amyloid polyneuropathy.
  • Miscellaneous — Polycystic disease of the liver.
  • Miscellaneous — Porto-pulmonary hypertension (pulmonary hypertension associated with liver disease or portal hypertension) in persons with a mean pulmonary artery pressure by catheterization of less than 35 mm Hg.
  • Miscellaneous — Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen overdose, etc.).
  • Miscellaneous — Trauma.
  • Miscellaneous — Hepato-pulmonary syndrome, covered when ALL of the following selection criteria are met: arterial hypoxemia (PaO2 less than 60 mm Hg OR AaO2 gradient greater than 20 mm Hg in supine or standing position); AND chronic liver disease with non-cirrhotic portal hypertension; AND intrapulmonary vascular dilatation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography).
  • Retransplantation following a failed liver transplant is medically necessary IF the initial transplant was performed for a covered indication.
  • Compatibility testing of prospective liver donors is medically necessary for living donor liver transplantation. (Compatibility testing and related services of the prospective live donor, as well as inpatient care of a compatible live donor for the donation procedure, may be covered under the member's medical benefit.)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • To override the active-substance-abuse contraindication: supporting documentation (dated within 4 weeks) demonstrating 3 months of stability, from a treating addiction medical professional or psychiatrist.

Frequently asked questions

When does Aetna cover Liver Transplantation (CPT 47133), and what gets it denied?
Aetna CPB 0596 covers orthotopic liver transplantation (cadaveric, reduced-size, living-related, or split-liver) as medically necessary for end-stage liver disease from a defined list of cholestatic, hepatocellular, vascular, metabolic, miscellaneous, and select malignant conditions, but only when the patient also clears the eligibility gate (MELD greater than 10, UNOS Regional Review Board approval, or the transplant institution's selection criteria; children under 12 must meet institutional criteria). Retransplantation is covered if the original transplant was for a covered indication, and living-donor compatibility testing is covered. Transplantation is not medically necessary in the presence of listed absolute contraindications (e.g., active sepsis outside the biliary tract, non-liver/kidney/small-bowel organ failure, active substance abuse unless 3 months of documented stability), and a long list of adjunct tests, perfusion systems, biomarkers, drugs, and alternative transplant techniques (e.g., machine perfusion, hepatocyte transplantation, MARS for PFIC, xenotransplantation) are considered experimental/investigational and not covered. Coverage criteria include: ELIGIBILITY GATE (Section I.A) — Adolescents 12 years or older AND adults qualify with ONE of: MELD score greater than 10; OR approved for transplant by the UNOS Regional Review Board; OR meet the transplant institution's selection criteria.; ELIGIBILITY GATE (Section I.A) — Children less than 12 years of age who meet the transplanting institution's selection criteria.; In the ABSENCE of an institution's selection criteria, requests are subject to medical necessity review for children, and for adolescents/adults with a MELD score of 10 or less who have not been approved by the UNOS Regional Review Board.; Orthotopic liver transplantation (cadaveric, reduced-size, living related, or split liver) is medically necessary for end-stage liver disease (ESLD) due to a covered condition in a member who ALSO meets the Section I.A eligibility gate.; Cholestatic disease — Biliary atresia.; Cholestatic disease — Familial cholestatic syndromes.; Cholestatic disease — Primary biliary cirrhosis.; Cholestatic disease — Primary sclerosing cholangitis with development of secondary biliary cirrhosis.; Hepatocellular disease — Alcoholic cirrhosis.; Hepatocellular disease — Chronic active hepatitis with cirrhosis (hepatitis B or C).; Hepatocellular disease — Cryptogenic cirrhosis.; Hepatocellular disease — Idiopathic autoimmune hepatitis.; Hepatocellular disease — Post-necrotic cirrhosis due to hepatitis B surface antigen negative state.; Malignancy — Primary hepatocellular carcinoma confined to the liver, covered when ALL of: any lung metastases have been shown to be responsive to chemotherapy; AND member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lymph nodes, abdominal organs, bone or other sites; AND there is no macrovascular involvement.; Malignancy — Hepatoblastomas in members less than 12 years of age, covered when ALL of: member is not a candidate for subtotal liver resection; AND member meets UNOS criteria for tumor size and number; AND there is no identifiable extra-hepatic spread of tumor to surrounding lungs, abdominal organs, bone or other sites. (Spread of hepatoblastoma to veins and lymph nodes does NOT disqualify the member.); Malignancy — Epithelioid hemangioendotheliomas.; Malignancy — Intra-hepatic cholangiocarcinomas (i.e., cholangiocarcinomas confined to the liver).; Malignancy — Large, unresectable fibrolamellar HCCs.; Malignancy — Metastatic neuroendocrine tumors (carcinoid tumors, apudomas, gastrinomas, glucagonomas) in persons with severe symptoms and with metastases restricted to the liver, who are unresponsive to adjuvant therapy after aggressive surgical resection including excision of the primary lesion and reduction of hepatic metastases.; Vascular disease — Budd-Chiari syndrome.; Vascular disease — Veno-occlusive disease.; Metabolic disorder / metabolic liver disease with cirrhosis — Alpha 1-antitrypsin deficiency.; Metabolic disorder / metabolic liver disease with cirrhosis — Hemochromatosis.; Metabolic disorder / metabolic liver disease with cirrhosis — Inborn errors of metabolism.; Metabolic disorder / metabolic liver disease with cirrhosis — Protoporphyria.; Metabolic disorder / metabolic liver disease with cirrhosis — Wilson's disease.; Miscellaneous — Familial amyloid polyneuropathy.; Miscellaneous — Polycystic disease of the liver.; Miscellaneous — Porto-pulmonary hypertension (pulmonary hypertension associated with liver disease or portal hypertension) in persons with a mean pulmonary artery pressure by catheterization of less than 35 mm Hg.; Miscellaneous — Toxic reactions (fulminant hepatic failure due to mushroom poisoning, acetaminophen overdose, etc.).; Miscellaneous — Trauma.; Miscellaneous — Hepato-pulmonary syndrome, covered when ALL of the following selection criteria are met: arterial hypoxemia (PaO2 less than 60 mm Hg OR AaO2 gradient greater than 20 mm Hg in supine or standing position); AND chronic liver disease with non-cirrhotic portal hypertension; AND intrapulmonary vascular dilatation (as indicated by contrast-enhanced echocardiography, technetium-99 macroaggregated albumin perfusion scan, or pulmonary angiography).; Retransplantation following a failed liver transplant is medically necessary IF the initial transplant was performed for a covered indication.; Compatibility testing of prospective liver donors is medically necessary for living donor liver transplantation. (Compatibility testing and related services of the prospective live donor, as well as inpatient care of a compatible live donor for the donation procedure, may be covered under the member's medical benefit.). Applies to 8 codes: 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: To override the active-substance-abuse contraindication: supporting documentation (dated within 4 weeks) demonstrating 3 months of stability, from a treating addiction medical professional or psychiatrist. Policy exclusions and limitations: CONTRAINDICATION (not medically necessary) — Active sepsis outside the biliary tract.; CONTRAINDICATION (not medically necessary) — Inability to adhere to the regimen necessary to preserve the transplant, including homelessness, active substance abuse (e.g., alcohol, cocaine, crystal meth, heroin, methadone, and/or narcotics, etc.), and/or unstable psychiatric disease/psychosocial problem. EXCEPTION: the active-substance-abuse contraindication is allowed with supporting documentation (within 4 weeks) demonstrating 3 months of stability from a treating addiction medical professional or psychiatrist.; CONTRAINDICATION (not medically necessary) — Other effective medical treatments or surgical options are available.; CONTRAINDICATION (not medically necessary) — Presence of significant organ system failure other than kidney, liver or small bowel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Basiliximab for induction immunosuppression in individuals undergoing liver transplantation (LT).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Bioartificial liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Biomarkers (acid labile nitroso-compounds (NOx), serum amyloid A protein, procalcitonin, peripheral blood T-cell activation, interleukin 2 (IL-2) receptor, guanylate-binding protein-2 mRNA, graft-derived cell-free DNA, pi-glutathione S-transferase, alpha-glutathione S-transferase and serum HLA class I soluble antigens) for diagnosis of acute allograft rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ectopic or auxiliary liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Everolimus to prevent organ rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Factor V Leiden and F2 testing for member scheduled to receive partial liver transplant for primary sclerosing cholangitis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hepatocellular (hepatocyte) transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hypothermic machine perfusion for reduction of the incidences of early allograft dysfunction and biliary complications after LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver elastography and Doppler examination of the portal veins and hepatic arteries for routine yearly surveillance following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for malignancies other than those listed as covered above.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for the treatment of extra-hepatic hilar cholangiocarcinoma.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Measurements of plasma and urinary neutrophil gelatinase-associated lipocalin (NGAL) for predicting acute kidney injury following orthotopic liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Molecular Adsorbent Recirculating System (MARS) for the treatment of progressive familial intrahepatic cholestasis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Normothermic machine perfusion of donor liver.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — OrganOx metra System for transportation and preservation of the liver prior to transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of vasopressin in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of sorafenib in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Scaffold-based transplantation (combination of xeno-organ and cell transplantations) as an alternative for orthotopic LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Testing of high mobility group box protein 1 (HMGB1) gene polymorphisms for prediction of morbidity and mortality after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Transient elastography for diagnosis of acute cellular rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ursodeoxycholic acid (UDCA), adjuvant use to prevent acute cellular rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Xenotransplantation. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Liver Transplantation?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: To override the active-substance-abuse contraindication: supporting documentation (dated within 4 weeks) demonstrating 3 months of stability, from a treating addiction medical professional or psychiatrist.
What does Aetna exclude for Liver Transplantation?
Policy exclusions and limitations: CONTRAINDICATION (not medically necessary) — Active sepsis outside the biliary tract.; CONTRAINDICATION (not medically necessary) — Inability to adhere to the regimen necessary to preserve the transplant, including homelessness, active substance abuse (e.g., alcohol, cocaine, crystal meth, heroin, methadone, and/or narcotics, etc.), and/or unstable psychiatric disease/psychosocial problem. EXCEPTION: the active-substance-abuse contraindication is allowed with supporting documentation (within 4 weeks) demonstrating 3 months of stability from a treating addiction medical professional or psychiatrist.; CONTRAINDICATION (not medically necessary) — Other effective medical treatments or surgical options are available.; CONTRAINDICATION (not medically necessary) — Presence of significant organ system failure other than kidney, liver or small bowel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Basiliximab for induction immunosuppression in individuals undergoing liver transplantation (LT).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Bioartificial liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Biomarkers (acid labile nitroso-compounds (NOx), serum amyloid A protein, procalcitonin, peripheral blood T-cell activation, interleukin 2 (IL-2) receptor, guanylate-binding protein-2 mRNA, graft-derived cell-free DNA, pi-glutathione S-transferase, alpha-glutathione S-transferase and serum HLA class I soluble antigens) for diagnosis of acute allograft rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ectopic or auxiliary liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Everolimus to prevent organ rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Factor V Leiden and F2 testing for member scheduled to receive partial liver transplant for primary sclerosing cholangitis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hepatocellular (hepatocyte) transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Hypothermic machine perfusion for reduction of the incidences of early allograft dysfunction and biliary complications after LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver elastography and Doppler examination of the portal veins and hepatic arteries for routine yearly surveillance following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for malignancies other than those listed as covered above.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Liver transplantation for the treatment of extra-hepatic hilar cholangiocarcinoma.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Measurements of plasma and urinary neutrophil gelatinase-associated lipocalin (NGAL) for predicting acute kidney injury following orthotopic liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Molecular Adsorbent Recirculating System (MARS) for the treatment of progressive familial intrahepatic cholestasis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Normothermic machine perfusion of donor liver.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — OrganOx metra System for transportation and preservation of the liver prior to transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of vasopressin in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Peri-operative use of sorafenib in liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Scaffold-based transplantation (combination of xeno-organ and cell transplantations) as an alternative for orthotopic LT.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Testing of high mobility group box protein 1 (HMGB1) gene polymorphisms for prediction of morbidity and mortality after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Transient elastography for diagnosis of acute cellular rejection following liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Ursodeoxycholic acid (UDCA), adjuvant use to prevent acute cellular rejection after liver transplantation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Xenotransplantation. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0596 — Liver Transplantation

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0596 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.