A client health system came to Applied Policy when it faced an untenable choice: either turn away Medicare beneficiaries with intrahepatic cholangiocarcinoma (iCCA) or absorb the $800,000 to $900,000 cost of unreimbursed liver transplants. The dilemma arose because, when the Centers for Medicare & Medicaid Services (CMS) issued a National Coverage Determination (NCD) on liver transplantation in 2001, it explicitly excluded certain cancers, including iCCA, from coverage. At the time, this decision reflected clinical realities: outcomes were poor, with recurrence in more than half of cases.
In the years since, advances in treatment and transplant protocols have transformed outcomes. For carefully selected patients, liver transplantation now offers a life-prolonging—and in some cases life-saving—option. Recent studies show five-year survival rates exceeding 50 percent, approaching those seen in hepatocellular carcinoma, which Medicare already covers under defined criteria. Yet CMS has not revised its original NCD, leaving Medicare beneficiaries with iCCA categorically excluded from a potentially curative intervention.
To help its client address these financial and clinical constraints, Applied Policy partnered with transplant specialists, medical societies, and patient advocates to compile outcome data, analyze peer-reviewed literature, and coordinate stakeholder input in support of a formal request for reconsideration.
The goal is to ensure that Medicare beneficiaries with iCCA are no longer denied access to potentially curative interventions due to outdated policy, and to support the hospital in sustaining the innovative care that has made this progress possible.
