118 Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exc

Data System for Organ Procurement and Transplantation Network

118. Liver Hepatocellular Carcinoma (HCC) MELDPELD Score Exception Extension Form_Form.xlsx

Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form

OMB: 0915-0157

Document [xlsx]
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Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form
Fields to be completed by members



Form Section Field Label Notes
Diagnosis Transplant Center Display Only
Diagnosis Name Display Only
Diagnosis Date of birth Display Only
Diagnosis Waitlist ID Display Only
Diagnosis SSN Display Only
Diagnosis ABO Display Only
Diagnosis Diagnosis
Diagnosis Candidate MELD/PELD data Display Only
Details Hepatocellular carcinoma (HCC)
Details Number of Tumors
Details Size
Details CT of abdomen Date
Details MRI of abdomen Date
Additional Corroborating Data Alpha-fetoprotein (AFP)
Additional Corroborating Data Alpha-fetoprotein (AFP) - Date
Additional Corroborating Data Previously Reported Loco-Regional Treatments Display Only
Additional Corroborating Data Are there any newer Loco-Regional Treatments to be reported?
New Loco-Regional Treatments Chemical ablation Date
New Loco-Regional Treatments Chemoembolization Date
New Loco-Regional Treatments External beam radiation Date
New Loco-Regional Treatments Histotripsy Date
New Loco-Regional Treatments Radiation microspheres Date
New Loco-Regional Treatments Thermal ablation Date
New Loco-Regional Treatments Other Date
Additional Required Questions Has the patient been resected since the initial HCC application?
Results Review results Display Only
Score Policy score for candidates meeting standard criteria Display Only
Score Please request an exception score
Score Justification narrative
Confirm Transplant physician name
Confirm Transplant physician NPI
Confirm Email decision to






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

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