Liver Transplant denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for immediate referral for a liver transplant. Early liver transplant in the setting of decompensated alcoholic liver disease, defined as before six months of abstinence from alcohol, is recommended for carefully selected patients with severe medically refractory alcohol associated liver disease who are considered to be at low risk for alcohol relapse post-transplant (Crabb, et al.). Weinberg and colleagues reported that early liver transplantation has been successfully performed in patients with severe alcohol associated hepatitis and prior liver decompensation. This patient presents with a history of alcohol use disorder, alcohol withdrawal seizures, chronic pancreatitis, and alcohol-associated hepatitis.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a liver transplant. Metastatic carcinoid or neuroendocrine tumor is a rare cancer that is generally not responsive to cytotoxic chemotherapy. This patient has a metastatic neuroendocrine tumor that is currently restricted to the liver. Since this patient's diagnosis, the patient’s medical care has very closely adhered to National Comprehensive Cancer Network (NCCN) guideline recommendations. However, at this time, the patient has exhausted all standard treatment options and is therefore being considered for transplant. A liver transplant is a reasonable next step for this patient who has tried and failed several standard therapies.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for liver transplant. Early liver transplant in the setting of decompensated alcoholic liver disease, defined as before six months of abstinence from alcohol, is recommended for carefully selected patients with severe medically refractory alcohol associated liver disease who are considered to be at low risk for alcohol relapse post-transplant (Crabb, et al.). One study reported by Weinberg and colleagues states that early liver transplantation has been successfully performed in well-selected patients with severe alcohol associated hepatitis and prior liver decompensation. This patient presents with a history of alcohol use disorder.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liver transplant (CPT 47135). This patient has a metastatic neuroendocrine tumor (NET) with involvement of numerous liver metastases, mass in the tail of the pancreas, ascites and possible lymph node involvement. Although this patient has a well-differentiated tumor, the patient also has several risk factors for recurrence or inferior survival including symptomatic tumor, a primary tumor in the pancreas, and greater than 50% involvement of the liver. The patient may have extrahepatic spread as noted by ascites and lymphadenopathy (Moris, et al.). Liver transplantation has been used in the past for patients with isolated metastases to the liver with mixed results. The proposal in this case is for living donor liver transplantation.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Liver Transplant, then check the rights and deadlines that apply to your plan.