Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colorectal Cancer with Liver Metastases

Treatment: Evaluation for liver transplant procedure when billed with diagnosis code C18.9 malignant neoplasm of colon, unspecified and C78.7 secondary malignant neoplasm of liver and intrahepatic bile duct

The insurer denied coverage for evaluation for liver transplant procedure when billed with diagnosis code C18.9 malignant neoplasm of colon, unspecified and C78.7 secondary malignant neoplasm of liver and intrahepatic bile duct

The denial is overturned

This is the case of an adult who was reviewed at the hepatobiliary multidisciplinary tumor board as of the progress note. The diagnosis was metastatic colorectal cancer isolated to the liver, status post systemic therapy and sigmoid colectomy. Magnetic resonance imaging (MRI) and computed tomography (CT) were reviewed, which noted bi-lobar disease with a right lobe lesion and 7 small lesions in the left hepatic lobe. Carcinoembryonic antigen (CEA) was 0.3 in comparison to CEA of 734. The recommendation was to refer the patient to liver transplant for metastatic colorectal cancer protocol. The provider saw the patient and reviewed the history which included colectomy, chemotherapy and plans for liver transplant versus resection with portal vein embolization. It was felt that the patient was an excellent medical and surgical candidate. The case was to be presented at the hepatobiliary case conference. The patient received infusion chemotherapy and tolerated it well. The MRI was included, showing multiple liver metastases which were better delineated on CT. CEA was 0.3.

According to Milliman Care Guidelines (MCG) Health: Inpatient and Surgical care 27th Edition: Liver transplant ORG:S-795 (ISC):

Procedure is indicated for ALL of the following: Transplant needed for 1 or more of the following: Acute liver failure (also known as "fulminant liver failure"); Severe chronic liver disease; Hepatocellular carcinoma; Cholangiocarcinoma; Neuroendocrine tumor; Colorectal liver metastases and ALL of the following: Primary tumor resected with clear margins, Histology is not signet ring cell carcinoma or undifferentiated adenocarcinoma, No evidence of extrahepatic metastatic disease on Positron Emission Tomography (PET)-CT scan, Liver metastases are not resectable, Molecular marker BRAF V600E is absent, Patient is not immunotherapy candidate, Metastatic lesions do not progress during at least 6 months of observation following bridging chemotherapy. 

In Hernandez-Alejandro R. et al. (2022), the authors examined the survival outcomes of living donor liver transplant recipient with unresectable liver confined colorectal metastases. This was a prospective cohort study in living donor recipients. The authors concluded that, "recurrence-free and overall survival rates suggest that select patients with unresectable, liver-confined colorectal liver metastases (CRLMs) may benefit from total hepatectomy and living-donor liver transplantation (LDLT)."

This is a young patient with metastases limited to the liver from their colon cancer. The patient meets guidelines for a liver transplant, as noted by MCG. It should be recognized that the request is for the patient to be evaluated for liver transplant, as this is the first step for this patient. Based on the above findings, an evaluation for liver transplant procedure is medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for evaluation for liver transplant procedure when billed with diagnosis code C18.9 malignant neoplasm of colon, unspecified and C78.7 secondary malignant neoplasm of liver and intrahepatic bile duct is substantiated.