Medical Policy

This document addresses hand transplantation for individuals with an amputated hand. Hand transplantation is a type of vascularized composite allograft (VCA) allogenic transplantation involving multiple tissue types such as skin, connective tissue, blood vessels, bone, muscle and nerves. The goal of hand transplantation is functional restoration, rather than survival.

Note: Please see the following related document for additional information:

• CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
• TRANS.00037 Uterine Transplantation

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Investigational and Not Medically Necessary:

Hand transplantation is considered investigational and not medically necessary.

This document describes clinical studies and expert recommendations, and explains whether hand transplantations are clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Hand transplantation is a surgery that replaces a missing hand with a donor hand. It is a type of transplant that includes skin, muscles, bones, blood vessels, nerves, and connective tissue. The goal is to restore function, movement, and feeling. Some studies show that hand transplantation may improve daily function and quality of life for some people. However, the surgery also has major risks. People who receive a transplanted hand need lifelong medicines to prevent rejection, which is when the body attacks the transplanted tissue. These medicines can cause serious side effects, including infections, organ damage, cancer, and metabolic problems. Studies have also shown that some transplanted hands later needed to be removed because of rejection or other complications. Research comparing hand transplantation with advanced prosthetic hands found that function was often similar between the two options. Better studies are needed to know if hand transplantation improves health more than other available treatments.

What the Studies Show

Hand transplantation has been performed in a small number of people around the world. Studies show that some people obtained movement, grip strength, and feeling after surgery. In one review of 96 people who received 148 transplanted hands between 1998 and 2019, disability scores improved after surgery. Some people also regained some ability to feel touch and grip objects. Researchers noted that many studies were small, used different methods, or had limited follow-up. This makes it difficult to know how well the treatment works over the long term.

Studies also found that complications were common. Many people had episodes of rejection, and some needed the transplanted hand removed. In one review, about 11% of transplanted hands were amputated after surgery. Some removals happened after people stopped taking anti-rejection medicines. Other serious problems included blood flow problems, infections, blood clots, and shock. A study comparing hand transplantation with myoelectric prosthetic hands found no major differences in hand function between the groups. Myoelectric prostheses use electrical signals from the body’s muscles to help control an artificial hand. Prosthetic hands do not require lifelong anti-rejection medicines or additional transplant surgeries, but they do not restore normal feeling.

Is this Clinically Appropriate?

Hand transplantation is not clinically appropriate because it has not been proven to improve health more than other available options.

Studies show that some people may have better function after transplantation, but the treatment also has serious risks. Many people experience rejection episodes, require lifelong anti-rejection medicines, or develop major complications such as infections, organ damage, cancer, or blood flow problems. Some transplanted hands later need to be removed. Research comparing hand transplantation with prosthetic hands did not show clear differences in function between the two treatments. Better studies are needed to know if hand transplantation improves health.

(Return to Description/Scope)

Summary

As of 2019, fewer than 150 hand transplants had been performed worldwide. The available data suggest that these procedures can result in functional improvement, including decreased Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores and some sensory and grip strength recovery. However, complications such as acute and chronic rejection are common and data show over a 10% amputation rate, generally related to immunosuppression withdrawal. United States (U.S.) data from 1999 to 2018 show that most recipients experience at least one rejection episode and have variable functional outcomes. A 2016 comparison of hand transplants and prosthetics found no significant differences in functional outcomes. The American Society for Surgery of the Hand (ASSH) council recommends the procedure only for carefully selected individuals and within specialized centers. Overall, current evidence does not support an improvement in the net health outcome with hand transplantation.

Discussion

A 2022 systematic review by Wells and colleagues identified 96 individuals who received 148 hand transplants (44 unilateral and 52 bilateral) between 1998 and 2019. Data on acute rejection episodes were available for 57 individuals who had a mean follow-up of 72 months (range, 2 months to over 10 years). The number of rejection episodes for these 57 individuals ranged from 0 to 13, and 28% of individuals experienced 1 episode. The median onset of the first episode of rejection was 55 days after transplantation (range, 3 days to 54 months). Chronic rejection was reported for 5 individuals. Functional outcomes were most consistently measured using the DASH score, scored from 0 (no disability) to 100 (most severe disability). Preoperative and postoperative DASH scores were available for 31 transplants in 18 individuals. In these individuals, the median preoperative DASH score was 71 (range, 25 to 100) and the median postoperative DASH score was 31 (range, 7 to 86). DASH scores decreased (improved) significantly after transplantation (p<0.001). Sensory recovery measured by the Semmes-Weinstein monofilament test was reported for 30 transplants and there was a median score of 4.06 mm. Grip strength, reported for 22 transplants, was a mean of 9.7 kg (range, 0.3 to 20kg). Additionally, 16 of the 148 hand transplants (10.8%) were amputated during follow-up. The most common factor leading to amputation, in 33% of the cases, was acute rejection following immunosuppression withdrawal. Other factors included chronic rejection, distal ischemia, septic shock and intraoperative arterial thrombosis. Limitations include heterogeneity of data sources, reliance on case reports and media reports, lack of standardized reporting, inability to perform formal meta-analysis, and small sample sizes with variable follow-up, all of which limit generalizability and statistical power.

In 2020, Hein and colleagues published a review of hand transplants in the U.S. using data collected by the Organ Procurement and Transplantation Network (OPTN). The authors reviewed data from 1999 through 2018. They identified a total of 32 individuals who received hand transplants in the U.S., 22 prior to July 3, 2014, and another 10 between that time and December 31, 2018. Outcome data were reported for the individuals who received transplants after July 3, 2014. DASH scores were available for 6 of the 10 individuals. At baseline, DASH scores ranged from 42 to 72 and, at the latest follow-up point, DASH scores ranged from 43 to 82. There were 3 individuals who had a decrease in DASH scores, 1 had an increase in the score and the other 2 had only 1 data point. Semmes-Weinstein monofilament test results were reported for 6 individuals including2 who had a grade of 5 (normal sensation) at their latest follow-up. Additionally, 2 individuals had diminished light sensation, and a grade of 4 while 2 individuals had an absence of protective sensation or non-testable sensation. Complications were frequent with 9 of 10 individuals experiencing at least 1 episode of rejection, with a range of 1 to 38 acute rejection episodes per person. This included 4 of 10 who had episodes of grade II-IV histologic rejection and 1 individual experienced graft failure 5 days after transplantation. Limitations include retrospective study with small sample size, incomplete and inconsistent data reporting, lack of standardized outcome definitions, reporting inconsistencies and variability across centers which further limit statistical analysis and generalizability.

A study comparing outcomes after hand transplantation and prosthetics in individuals with below-elbow amputation was published in 2016 by Salminger and colleagues. The study included 12 individuals, 5 of which had hand transplantation and 7 of which had prosthetics. This included 2 hand transplantation recipients who had bilateral procedures and hence 7 hand transplants were compared with 7 prosthetic hands. Several types of myoelectric prosthetics with simple direct control were used, depending on the individual’s exact level of amputation. Functional outcome measures included the DASH, the Action Research Arm Test (ARAT), maximum score of 57 points, and the Southampton Hand Assessment Procedure (SHAP), maximum score of 100 points indicating normal hand function. The mean DASH score was 22.5 (standard deviation [SD], 19.7) in transplanted hands and 10.8 (SD, 6.4) in prosthetic hands; scores did not differ significantly between groups, p=0.40. The mean ARAT scores were 40.9 (SD, 8.1) in the transplanted hands and 39.0 (SD, 3.6) in the prosthetic hands, with a non-significant between-group difference, p=0.87. The SHAP scores also did not differ significantly between groups (p=0.98); mean scores were 75.0 (SD, 11.1) in the transplanted hands and 75.4 (SD, 10.8) in the prosthetic hands. The SF-36 Health Survey (SF-36), which is sub-divided into 8 scales, 4 for physical health and 4 for mental health, was used to measure quality of life; each scale is scored with a maximum of 100 points. The authors did not report an overall SF-36 score. Three of four physical health scales (physical functioning, bodily pain and general health) did not differ significantly between groups and the fourth (role-physical) favored the hand transplant group. Three of the four mental health scales, vitality, role-emotional, and mental health, but not social functioning, were significantly higher in the hand transplantation group compared with the prosthetics group.

In 2013, the ASSH Council published the following statement on hand transplantation:

At this time, the American Society for Surgery of the Hand recognizes that hand transplantation represents an alternative to prosthetic fitting and rehabilitation in appropriately selected patients. However, advances should continue to be made in the areas of patient selection, surgical technique, and immunosuppression. Additional challenges include the funding of patients for these procedures and for lifelong immunosuppressive treatment. This procedure may have substantial merit in properly selected recipients. Nevertheless, for the present it should be carried out only in centers with extensive experience in both hand surgery and solid organ transplantation.

Hand transplantation is a type of vascularized composite allograft (VCA) transplantation. Prior to 2014, VCA was known as vascularized composite allotransplantation (Hein, 2020). In the United States (U.S.), in 2014 VCAs were added to the Final Rule which refers to the federal regulations that govern  how the Organ Procurement and Transplantation Network (OPTN) operates. This addition means mandatory data reporting to OPTN is required for VCAs. The OPTN/Scientific Registry of Transplant Recipients (SRTR) (Hernandez, 2022) reported that “the Final Rule defined VCA transplantation as the transplant of any body part that meets the following nine criteria:

1. Vascularized and requires blood flow by surgical connection of blood vessels to function after transplant
2. Contains multiple tissue types
3. Recovered from a human donor as an anatomical/structural unit
4. Transplanted into a human recipient as an anatomical/structural unit
5. Minimally manipulated (ie, processing that does not alter the original relevant characteristics of the organ relating to the organ’s utility for reconstruction, repair, or replacement)
6. For homologous use (the replacement or supplementation of a recipient’s organ with an organ that performs the same basic function or functions in the recipient as in the donor)
7. Not combined with another article such as a device
8. Susceptible to ischemia and, therefore, only stored temporarily and not cryopreserved
9. Susceptible to allograft rejection.”

The first successful hand transplant was performed in France in 1998 and, since that time, between 100 and 200 procedures have been performed worldwide, with approximately 30 of these done in the U.S.. There have also been at least 24 amputations of transplanted hands due to factors such as bacterial infection, multiple rejection episodes or arterial ischemia (Lúcio, 2021).

The 2022 OPTN/SRTR annual report on VCA transplant (Hernandez, 2024) reported that 34 of 56 (60.7%) listed individuals had undergone nonuterus VCA between 2014 and 2022. The most common type of nonuterus VCA procedure performed was upper limb transplant (44%). The report did not specifically mention hand transplantations.

In 2025, the Department of Defense (DoD) Reconstructive Transplant Research Program commissioned the National Academies to develop a framework for standardizing and evaluating clinical protocols and procedures in face and hand transplantation. The resulting report provided guidance for the Clinical Organization Network for Standardization of Reconstructive Transplantation (CONSORT) and outlines recommendations aimed at strengthening and advancing the broader VCA field. They identified recommendations based on five conclusions:

First, face and hand transplantation are innovative and potentially transformative treatment options for select individuals, but should be performed only at specialized centers with experienced, multidisciplinary teams capable of delivering safe, ethical care and providing lifelong support to recipients and their caregivers.

Second, given the complexity of transplantation and the need for lifelong management, a comprehensive “whole health” approach is essential, addressing the medical, psychological, and social needs of both recipients and their support systems.

Third, the field would benefit from greater standardization of pre-, intra-, and post-transplant protocols, including consistent approaches to participant selection, management, monitoring, and support for informed decision-making.

Fourth, the establishment of a centralized, accessible, and adaptable participant registry is needed to systematically collect and analyze procedural and outcome data, supporting clinical care, research, and long-term follow-up.

Fifth, continued collaboration across transplant centers, along with sustained research efforts, is critical to advancing the scientific foundation and long-term success of face and hand transplantation.

Hand transplantation is an alternative to use of hand prosthetic fitting, and both interventions have potential benefits and risks. In contrast to prosthetics, transplantation provides the opportunity for both sensory restoration and recovery of fine motor control.. Moreover, hand transplantation can have psychological benefits such as a sense of wholesomeness and bodily integrity. However, hand transplant recipients require ongoing rehabilitation and lifelong treatment with immunosuppressive drugs. Possible adverse effects include acute and chronic rejection, infection, neoplasia, metabolic disorders, and organ failure. Prosthetic hand technology has advanced and myoelectric prostheses, which are controlled by electromyographic (EMG) signals generated naturally by an individual’s own muscles, and can substantially replace motor function. Hand prosthetics also have the advantages of not requiring lifelong medication, they can be fit shortly after the injury and they do not require additional surgeries. Disadvantages include the lack of sensory information which makes it difficult to perform precise motor tasks, which might lead the individual to abandon the prosthetic device.

Allogeneic transplantation: The transplantation of cells, tissues, or organs to an individual from a donor who is not genetically identical (for example, not an identical twin).

Myoelectric: Electric signals that stimulate muscles to move. These electrical impulses can be amplified and used to control artificial limbs.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure codes or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Hein RE, Ruch DS, Klifto CS, et al. Hand transplantation in the United States: a review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database. Am J Transplant. 2020; 20(5):1417-1423.
2. Lúcio MJ, Horta R. Hand transplantation-risks and benefits. J Hand Microsurg. 2020; 13(4):207-215.
3. Salminger S, Sturma A, Roche AD, et al. Functional and psychosocial outcomes of hand transplantation compared with prosthetic fitting in below-elbow amputees: a multicenter cohort study. PLoS One. 2016; 11(9):e0162507.
4. Wells MW, Rampazzo A, Papay F, Gharb BB. Two decades of hand transplantation: a systematic review of outcomes. Ann Plast Surg. 2022; 88(3):335-344.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society for Surgery of the Hand Council. ASSH position statement on hand transplantation 2013. J Hand Surg Am. 2013; 38(11):2234-2235.
2. Hernandez JA, Miller JM, Emovon E 3^rd, et al. OPTN/SRTR 2022 annual data report: vascularized composite allograft. Am J Transplant. 2024; 24(2S1):S534-S556.
3. Hernandez JA, Miller J, Oleck NC, et al. OPTN/SRTR 2020 annual data report: VCA. Am J Transplant. 2022; 22 Suppl 2:623-647.
4. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Board on Health Care Services; Committee on Principles and Framework to Guide the Development of Protocols and Standard Operating Procedures for Face and Hand Transplants; Cooper R, Kizer KW, editors. Advancing face and hand transplantation: principles and framework for developing standardized protocols. Washington (DC): National Academies Press (US); 2025 May 28. 9, Overarching Conclusions and Recommendations. Available at: https://www.ncbi.nlm.nih.gov/books/NBK615570/. Accessed on July 30, 2026.

Vascularized composite allograft

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