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University of Pittsburgh Surgeons Urge Medicare to Cover Living Liver Donation and Transplants

BALTIMORE, December 3, 2001 — Patients needing liver transplants who are covered by Medicare ought to have the same opportunities to receive life-saving transplants as do other patients, say surgeons from the University of Pittsburgh Medical Center (UPMC) who are urging the Centers for Medicare and Medicaid(CMS) to cover living donor liver transplantation.

While many private insurance carriers pay for the living donor transplant procedure, Medicare’s policies have not kept pace with advancements in the field. UPMC is hopeful that CMS will allow Medicare coverage for living liver donor transplants as it already does for living donor kidney and lung transplants.

Today, two surgeons from UPMC's Thomas E. Starzl Transplantation Institute will present data to CMS's Coverage and Analysis Group in hopes that the agency will conduct a full review that will result in a decision to cover the procedure. Their presentation coincides with the first meeting of the U.S. Department of Health and Human Services Advisory Committee on Organ Transplantation which today will discuss the issue of living donation. Secretary of Health Tommy Thompson has made organ donation one of his biggest priorities.

Adult-to-adult living donor liver transplants were first performed in Japan in 1994. Nearly 1,000 transplants have since been performed in Asia and Oceania. In the United States, the practice of adult-to-adult living donor liver transplants has greatly increased in recent years. In total, about 450 have been performed since 1996, beginning with just a handful that year to more than 200 cases in both 2000 and 2001 as surgeons have looked to ways to reduce the numbers of their patients who die awaiting transplants. More than 1,600 patients died waiting for liver transplants in the United States in 2000; the number of patients who will not survive the wait for donor organs this year most likely will be much higher.

"It is extremely frustrating that we cannot help those Medicare patients we feel would be good candidates for living donor liver transplantation. Frankly, there are some whose conditions are worsening and will probably die if we are to solely depend on the availability of cadaveric donor organs," said John J. Fung, M.D., Ph.D., the Thomas E. Starzl Professor of Transplantation Surgery and chief of transplant surgery at the Starzl Institute.

"In some cases we have had family members who were willing to be medically evaluated for the donor operation and their private insurance companies were willing to pay for the donor surgery expenses if they were deemed suitable for donation. Yet our regional fiscal intermediary for Medicare refused to pay for the recipient's transplant," said Bijan Eghtesad, M.D., associate professor of surgery and co-director of the adult live donor liver transplant program at the Starzl Institute.

Last summer, Dr. Eghtesad wrote to CMS asking that the agency consider establishing a national policy to cover living liver donor transplants after several unsuccessful attempts to convince regional CMS officials that the benefits of the surgery to both the donor and the recipient outweighed the potential risks. Because a number of centers perform the procedure, with some centers performing nearly half of their transplants using living donors, there appeared to be discrepancies in what different regional offices were allowing transplant centers to do. Indeed, an informal survey conducted by University of Pittsburgh Medical Center indicated that some fiscal intermediaries for CMS were suggesting that centers bill the living liver donor evaluation and operation as if it were a donor acquisition charge; the way the procurement of cadaveric donor livers would be billed.

The University of Pittsburgh historically has represented a conservative voice with respect to living donation. Because there are risks to the donor -- an otherwise healthy individual -- with a mortality rate between .5 and 1 percent, the operation should only be performed at centers with considerable experience in cadaveric liver transplantation, split liver transplantation and liver resection operations. UPMC surgeons believe the operation should be considered as an option when both donors and recipients are carefully screened and selected and both fully understand and accept the risks involved.

The operation usually involves taking the donor's right lobe, the larger of the liver's two lobes, and transplanting it into the recipient. In an adult-to-child living donor operation, a segment of the left lobe is typically resected. In both types of surgeries, the donor's and recipient's livers are expected to grow back to a normal size within several weeks.

In the last year, UPMC surgeons have performed 12 adult-to-adult living donor liver transplants in patients who had an expected life expectancy of less than a year without transplantation. Since 1981, nearly 6,000 liver transplants have been performed at the University of Pittsburgh, numbers unmatched by any other center in the world.

The Starzl Transplantation Institute has had considerable success in influencing national policy for the benefit of all transplant patients. Last year, Medicare announced it would cover intestinal transplantation after an appeal was made by a University of Pittsburgh surgeon. Some months ago, CMS agreed to extend coverage for liver transplantation to include patients with hepatocellular carcinoma. UPMC surgeons had initiated the appeal in 1993 and in the last year worked closely with a handful of other centers and with CMS on its review.

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