Liver Cholangiocarcinoma (CCA) Initial MELD/PELD Score Exception Form

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Liver Cholangiocarcinoma (CCA) MELD/PELD Initial Exception Score Form

Diagnosis

The following fields, from the candidate's Waitlist record, are read-only. If the information is incorrect, it may be updated on the candidate's Waitlist record.

Transplant Center: Verify the transplant center code is correct.

Name: Verify the candidate's name is correct.

Date of birth: Verify the candidate's date of birth is correct.

Waitlist ID: Verify the candidate's Waitlist ID number is correct.

SSN: Verify the candidate's social security number is correct.

ABO: Verify the candidate's blood type is correct.

Diagnosis: Select the candidate's diagnosis from the drop-down list.

Cholangiocarcinoma (CCA)

Cystic fibrosis (CF)

Familial amyloid polyneuropathy (FAP)

Hepatic artery thrombosis (HAT)

Hepatocellular carcinoma (HCC)

Hepatopulmonary syndrome (HPS)

Metabolic disease

Portopulmonary hypertension

Primary hyperoxaluria

Other specify

Candidate MELD/PELD data: The fields, from the candidate's Waitlist record in the MELD/PELD Data Collection section, are read-only. Click view details to expand. Click hide details to collapse.

Details

Cholangiocarcinoma (CCA): If cholangiocarcinoma is selected for a candidate, complete the following questions:

Does the candidate meet the diagnostic criteria for hilar CCA with a malignant appearing stricture on cholangiography?: This is a required field.

If Yes, then select all that apply:

Biopsy or cytology results demonstrating malignancy

Carbohydrate antigen 19-9 greater than 100 U/mL in absence of cholangitis

Aneuploidy

Hilar mass less than 3.0 cm in radial diameter

Imaging studies performed: Indicate whether the imaging used to observe the candidate's tumor was a CT of abdomen and/or MRI of abdomen, and enter the date of the imaging study.

If image selected, then enter:

Number of tumors: Enter the number of tumors into the space provided. This is a required field.

If number of tumors greater than 0, then enter:

Tumor size: Enter the size of the tumor in cm. Tumor size must be between 1 and 99.99.

Is the tumor unresectable due to technical considerations or underlying liver disease?: If tumor is unresectable due to technical considerations or underlying liver disease, select Yes. If not, select No. If Yes is selected, select all that apply. This is a required field.

Have intrahepatic and extrahepatic metastases been excluded by cross-sectional imaging studies?: If intrahepatic and extrahepatic metastases have been excluded by cross-sectional imaging studies, select Yes. If not, select No. If Yes is selected, select all that apply. This is a required field.

Was a transperitoneal aspiration or biopsy of the primary tumor performed?: If a transperitoneal aspiration or biopsy of the primary tumor performed, select Yes. If not, select No. This is a required field.

Results

Review results: The candidate's result details display.

Score

Policy score for candidates meeting standard criteria: The policy score for candidates meeting standard criteria displays.

Please request an exception score: Select an exception score for the candidate:

Equal to the policy assigned score for candidates meeting standard criteria

Score adjusted from the median MELD at transplant (MMaT)

        Less than MMaT (the number must fall between 1 and 20)

        Equal to MMaT

        More than MMaT (the number must fall between 1 and 20)

MELD 40

PELD 40 or higher (for pediatric candidates; the number must fall between 40 and 99)

Justification narrative: Enter text justifying the requested higher MELD or PELD score. 8000 character limit. 

 Confirm

Transplant physician name: Enter the transplant physician's name. This is a required field.

Transplant physician NPI: Enter the transplant physician's NPI number. The NPI must be 10 digits. This is a required field.

Email decision to: Enter at least one and up to three email addresses to receive notification of the outcome of the vote. Including up to three email addresses may be important to account for time off or out-of-office. This is a required field.

Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. 

OPTN Restricted

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