Clinical Policy: Pediatric Liver Transplant Form

CENTENE
Corporation

Clinical Policy: Pediatric Liver Transplant
Reference Number: CP.MP.120
Date of Last Revision: 05/25

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
End-stage liver disease presents unique clinical considerations in the pediatric population. Liver transplantation provides a therapeutic option for pediatric patients with end stage disease. This policy establishes the medical necessity requirements for pediatric liver transplants.

Policy/Criteria

Background
Liver transplantation is an effective therapeutic option for an assortment of acute and chronic hepatic disorders that lead to end stage liver disease in the pediatric population. According to the practice guideline of the American Association for the Study of Liver Diseases (AASLD), pediatric liver transplants account for ~7.8% of all liver transplants in the United States.¹ The evaluation of children for liver transplants should include a multidisciplinary team of specialists that achieve psychosocial, neurocognitive, and developmental needs as well as the complex clinical necessities of these patients.

For adult liver transplants (and children ≥ 12 years of age), the Model for End-stage Liver Disease (MELD) formula is commonly utilized to determine assess organ allocation for liver candidates. The Pediatric End-stage Liver Disease (PELD) score was analogously developed for children < 12 years of age and utilizes total serum bilirubin, INR, height, weight, and albumin; however, this scoring system is not ubiquitously utilized.¹

Common indications for pediatric liver transplants are acute liver failure, biliary atresia and other cholestatic diseases, metabolic diseases, immune disorders, and hepatic malignancies. A recent multicenter analysis of the five-year survival of 461 children revealed an 88% survival rate for the first year.⁵ The majority of these children also show strong graft function at five years, but there are multiple chronic post-transplantation complications in extrahepatic organs.⁵

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and any available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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