*Purpose: We aim to compare waitlist (WL) outcomes for HCC patients after the implementation of the most recent UNOS exception policy change on 5/1/2019.

*Methods: All U.S. adults (≥18yrs) listed for LT from 4/30/13-9/4/20 using the UNOS registry were evaluated. Patients were categorized based on date of listing into 3 eras – Era 1: 4/30/13-10/7/15, Era 2: 10/8/15-4/30/19 (6-month delay and a maximum 34 points), and Era 3: 5/1/19-9/4/20 (median MELD at transplant – 3). WL outcomes were evaluated with multivariate competing risk models, adjusted for demographics, UNOS region, ascites, hepatic encephalopathy (HE), biologic MELD, liver disease etiology, era, HCC, and exception status. In analyses stratified by era, follow up time was limited to end of that era.

*Results: A total of 79,381 patients were listed for LT during the study period: 24,648 in Era 1, 39,536 in Era 2, and 15,197 in Era 3. The proportion of listed patients with HCC decreased from 25.7% in Era 1, 23.5% in Era 2, to 19.5% in Era 3. The proportion of HCC patients listed with exceptions also decreased from 74.0% in Era 1, 68.8% in Era 2, to 34.6% in Era 3. There was no significant difference in severity of ascites (p=0.06) or severity of HE (p=0.07) among HCC patients throughout the 3 eras. In Era 1, compared to non-HCC patients, HCC patients without exceptions (HR 1.30, p<0.001) and HCC patients with exceptions (HR 2.12, p<0.001) had a higher likelihood of LT. In Era 2, compared to non-HCC patients, HCC patients without exceptions (HR 1.10, p=0.003) and HCC patients with exception (HR 1.35, p<0.001) had a higher likelihood of LT. In Era 3, compared to non-HCC patients, HCC patients without exception had lower likelihood of LT (HR 0.90, p=0.04) while HCC patients with exceptions had a higher likelihood of LT (HR 1.60, p<0.001). In Era 1, HCC patients without exceptions had no significant difference in WL dropout/mortality compared to non-HCC patients, while HCC patients with exception had lower WL dropout/mortality (HR 0.82, p<0.001). In Era 2, HCC patients without exceptions had higher WL dropout/mortality (HR 1.30, p<0.001), while HCC patients with exceptions had no significant difference. In Era 3, HCC patients without exceptions continued to have higher WL dropout/mortality (HR 2.00, p<0.001) while HCC patients with exceptions had lower WL dropout/mortality (HR 0.35, p<0.001).

*Conclusions: Patients with HCC MELD exception saw an overall decline in the likelihood of LT after the two most recent policy changes. However, the advantage for HCC patients with MELD exception still remains. There was no significant increase in the dropout/mortality on the WL for the HCC MELD exception patients, instead there was improvement after the 2019 changes which may be due to shorter follow up time. Overall, the changes reflect gradual move towards desired equity.

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