Benefit Category
Inpatient Hospital Services
Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
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.
Claims Processing Instructions
