HCC policy changes affect applications for non-automatic exception requests

Published on: Monday, November 23, 2015

On October 8, 2015, changes were implemented OPTN Policies 9.3.F (Candidates with Hepatocellular Carcinoma (HCC)) and 9.3.F.vi (Extensions of HCC Exceptions). These changes are more widely known as the “HCC Delay” and “Cap HCC” policies.

• Under the “HCC Delay” policy, candidates with a new initial HCC exception application submitted on or after October 8 must be registered at their calculated MELD or PELD scores for the first three months (initial application) and for the first three-month extension, as long as the candidate continues to meet the policy criteria. At six months (second extension), MELD candidates will receive a score of 28, and PELD candidates will receive a score of 34.
• Under the “Cap HCC” policy, HCC exception scores are now capped at 34 for any HCC exception application submitted on or after October 8. HCC exception scores for candidates with an accumulated HCC exception score of 35 or higher on that date were reset to 34. Note: this policy applies to all candidates receiving exception priority due to the HCC criteria outlined in policy, regardless of when the initial application was made.

HCC exception scores have been updated for all liver candidates meeting policy criteria for automatic approval in the UNetSM system at the time of implementation. These updates were transparent to the centers where the candidates were listed.

HCC exception scores for candidates not meeting HCC criteria, whose applications are submitted to the regional review board (RRB), must still adhere to the policy and also the same scoring schedule as candidates who meet criteria for automatic approval. This includes exceptions submitted using the “Other Specify” dropdown when the center wishes to request HCC priority under the policy criteria.

In these circumstances, centers submitting an initial HCC application and subsequent 3-month extension should enter a MELD score of 6 or a PELD score of -99 as the requested score. Entering the appropriate score will allow UNet℠ to use the candidate’s calculated MELD/PELD score during the initial 3-months and first extension period. While the candidate is listed at the calculated score, the score is subject to the MELD/PELD recertification schedule (the same as would be required for a candidate without an exception).

We encourage centers to:

• Enter current lab values into Waitlist℠ at the time that an HCC application is being submitted. This will ensure that the candidate is listed at their current laboratory score.
• Utilize the “MELD/PELD Exceptions – Extension Management” report in Waitlist℠ to ensure that all candidates’ MELD/PELD appropriately certified; this is especially important for those with calculated scores of 19 and higher. For example, a candidate with a calculated MELD score of 20 would need to have the score recertified every month, with laboratory values that are no older than 7 days.

If the initial HCC request was submitted on or after October 8, 2015, RRBs should not approve requests for scores of 22 on the initial application, nor scores of 25 on the first extension, unless there are extenuating clinical circumstances, which should be stated clearly in the narrative text. Similarly, RRBs should not approve requests for scores higher than 34 unless there are extenuating clinical circumstances.

Liver transplant programs should review the exception scores for candidates with HCC exceptions and, if necessary, withdraw any exceptions that are outside current policy and submit a new request that meets the score assignments in policy.