Adult Liver Transplantation — NCD 70 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 70, the National Coverage Determination governing Medicare adult liver transplantation coverage policy, effective January 9, 2026. Here's what billing teams need to act on now.

This update to NCD 70 Medicare documentation consolidates the coverage framework for adult liver transplantation across multiple effective dates — from 1996 through 2012 — into a single, reviewable policy. The CMS liver transplantation coverage policy governs which indications qualify for Medicare reimbursement, which remain nationally non-covered, and which fall to Medicare Administrative Contractor (MAC) discretion at the local level. No specific CPT or HCPCS codes are listed in the current policy document, so your billing team will need to cross-reference your transplant center's charge master against the criteria outlined below.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Adult Liver Transplantation — NCD 70
Policy Code	NCD 70
Change Type	Modified
Effective Date	January 9, 2026
Impact Level	High
Specialties Affected	Transplant surgery, hepatology, oncology, inpatient hospital billing, revenue cycle
Key Action	Audit your facility's CMS approval status and confirm that documentation supports the specific covered indication before submitting claims

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CMS Adult Liver Transplantation Coverage Criteria and Medical Necessity Requirements 2026

The CMS adult liver transplantation coverage policy has layered coverage indications built up over nearly three decades. Each layer carries its own effective date and its own medical necessity criteria. Your billing team needs to know which layer applies to the patient's diagnosis — and document accordingly.

End-Stage Liver Disease (Non-Malignant, Non-Hepatitis B)

Coverage for end-stage liver disease excluding hepatitis B and malignancies became effective July 15, 1996. The single hard requirement: the procedure must be performed at a CMS-approved facility. There are no additional clinical criteria listed in the national policy for this indication beyond facility approval status.

If your facility lost CMS approval or is pending renewal, claims for this indication will deny. Verify approval status before submitting.

End-Stage Liver Disease Including Hepatitis B

CMS extended coverage to include hepatitis B-related end-stage liver disease on December 10, 1999. Again, the controlling requirement is CMS facility approval. Document the hepatitis B etiology clearly in the claim record — vague "end-stage liver disease" documentation leaves the door open for a medical necessity challenge.

Hepatocellular Carcinoma (HCC)

This is the most criteria-heavy covered indication. Effective September 1, 2001, Medicare covers adult liver transplantation for hepatocellular carcinoma when all five conditions are met:

Every one of these criteria must be documented. Missing even one — say, a radiology report that doesn't explicitly address macrovascular involvement — creates a claim denial risk. The Milan Criteria framework maps closely to these requirements, so if your transplant team uses that language, make sure it also maps explicitly to these five CMS criteria in the medical record.

MAC-Level Coverage for Certain Malignancies

Effective June 21, 2012, CMS gave Medicare Administrative Contractors the authority to determine coverage for three specific malignancy indications within their jurisdictions:

#	Covered Indication Copy
1	Extrahepatic unresectable cholangiocarcinoma (CCA)
2	Liver metastases due to neuroendocrine tumor (NET)
3	Hemangioendothelioma (HAE)

This matters a lot for your billing team. Coverage for CCA, NET, and HAE transplants is not nationally uniform. Your MAC may cover these — or may not. Contact your MAC directly before submitting claims for these indications. A local coverage determination (LCD) may exist in your jurisdiction that governs this. Do not assume coverage because another facility in a different MAC jurisdiction got paid.

Follow-Up Care and Re-Transplantation

Follow-up care and re-transplantation required as a result of a covered liver transplant are covered when the services are otherwise reasonable and necessary. This applies even for patients discharged after a non-covered liver transplant — follow-up care for that population is still covered if it meets Medicare's reasonable and necessary standard. Make sure your post-transplant billing workflows account for this distinction.

Immunosuppressive Drugs

The policy references immunosuppressive drug coverage under the Medicare Benefit Policy Manual, Chapter 15, §50.5.1 and the Medicare Claims Processing Manual, Chapter 17, §80.3. Immunosuppressive drug billing is governed separately. If your team handles post-transplant pharmacy billing, review those manual sections independently of this NCD.

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CMS Adult Liver Transplantation Exclusions and Non-Covered Indications

The policy is direct on this: adult liver transplantation for malignancies other than hepatocellular carcinoma — and the three MAC-discretionary indications (CCA, NET, HAE) — remains nationally non-covered.

That's a meaningful exclusion. If a patient presents with a primary liver malignancy that doesn't meet the HCC criteria or doesn't fall under CCA, NET, or HAE, there is no Medicare coverage pathway at the national level. The transplant would be non-covered, and billing Medicare for it creates a false claims exposure.

The real issue here is the MAC-discretionary middle ground. CCA, NET, and HAE aren't nationally non-covered — they're in a gray zone. Your MAC may or may not have issued an LCD covering them. If no LCD exists in your jurisdiction, the default is non-coverage. Check your MAC's website for active LCDs before proceeding.

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Coverage Indications at a Glance

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CMS Adult Liver Transplantation Billing Guidelines and Action Items 2026

The January 9, 2026 effective date on this modification means your billing team should treat these as active requirements now — not future ones.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Adult Liver Transplantation Under NCD 70

The current NCD 70 policy document does not list specific CPT, HCPCS, or ICD-10 codes. This is not unusual for an NCD of this age — codes were often managed through transmittals and claims processing instructions rather than embedded in the NCD text itself.

For liver transplantation billing, work with your MAC's claims processing transmittals and your charge master to identify the correct procedure codes. TN 2513 (Medicare Claims Processing) is referenced in the policy cross-reference section as the relevant transmittal. Pull that transmittal for code-level guidance.

Your coding team should also confirm ICD-10-CM diagnosis codes that map cleanly to each covered indication — particularly the HCC indication, where specificity of diagnosis coding directly supports the medical necessity documentation requirement.

If you need code-level guidance specific to your MAC jurisdiction, request a coverage determination or billing guidelines clarification directly from your MAC before submitting claims.

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