Medicare Coverage and Limitations for Liver Transplants

Medicare can cover liver transplants for qualified beneficiaries when certain conditions apply:

• The beneficiary must have end-stage liver disease.
• The end-stage liver disease must not be due to hepatitis or a malignancy other than hepatocellular carcinoma.
• The procedure must be conducted in a facility that meets institutional coverage criteria set by the Centers for Medicare & Medicaid Services (CMS).

Medicare's Coverage Criteria for Liver Transplants Due to Hepatocellular Carcinoma

Several forms of cancer may develop in the liver. Medicare only covers liver transplants due to hepatocellular carcinoma, the most common type of liver cancer. However, certain criteria apply:

• The beneficiary must not be a candidate for subtotal liver resection.
• The tumor must not have a diameter greater than or equal to 5 centimeters.
• There must be no macrovascular (large blood vessel) involvement.
• The tumor must not have spread to the lymph nodes, lungs, abdominal organs or bone.

Medicare Administrative Contractors have the authority within their jurisdictions to consider coverage for liver transplants arising from the following malignancies:

• Extrahepatic unresectable cholangiocarcinoma (CCA)
• Liver metastases due to a neuroendocrine tumor (NET)
• Hemangioendothelioma (HAE)

Medicare's Coverage for Follow-Up Care for Liver Transplants

• Medicare covers reasonable and necessary follow-up care for covered liver transplants.
• Medicare covers reasonable and necessary follow-up care for beneficiaries discharged from a hospital following noncovered liver transplants.

Medicare Coverage Breakdown for Liver Transplants

Medicare Part A is hospital insurance that pays for costs incurred for covered liver transplants performed in Medicare-certified facilities. These include:

• Medically necessary tests, labs and examinations
• Services for covered liver transplants
• Organ procurement
• Follow-up care
• Immunosuppressive drugs administered in the medically necessary and medically accepted dosage, frequency and route of administration
  
  

Medicare Part B is medical insurance that pays for doctors' services necessary for covered liver transplants performed in Medicare-certified facilities.

Beneficiary Cost Responsibility

After the beneficiary meets the applicable deductibles, Medicare Part B covers 80% of the reasonable and necessary medical costs involved in liver transplants as long as the transplant meets the established guidelines and the facility and providers accept Medicare assignment. The beneficiary is responsible for paying:

• The Medicare Part A and B deductibles
• The remaining 20% of the Medicare-approved amount of the doctor's services
• Certain transplant facility charges

Costs vary based on the types of facilities the beneficiary chooses and the providers' charges. Some of these costs may be covered by the beneficiary's secondary insurance.