*Purpose: The National Liver Review Board (NLRB) was implemented 5/14/2019, establishing a national structure for liver exceptions comprised of three specialty review boards and a scoring system based on the median score for the area of distribution. The area of distribution was revised with the implementation of Acuity Circles (AC) on 2/4/2020.

*Methods: OPTN exception requests, liver waitlist (WL) registrations, and deceased donor liver-alone transplant data was analyzed 18 months pre- (11/16/2017-5/13/2019) and post-policy (2/4/2020-7/31/2022). Time between NLRB and AC implementation (5/14/2019-2/3/2020) was excluded.

*Results: The proportion of auto-approvals significantly increased (51% post-policy vs. 23% pre-policy, p<0.001). Time for reviewers to resolve cases decreased (average 4.2 days post-policy vs. 3.8 days pre-policy, p<0.001). WL dropout rates increased for exception candidates, with similar rates for non-HCC exceptions and non-exceptions post-policy, and both non-exception and non-HCC exception transplant rates increased (Figure 1). There was a decrease in the proportion of transplants with an exception across adult and pediatric age groups (Figure 2).

*Conclusions: More exception forms were automatically approved, decreasing the burden on reviewers. Reviewers also resolved cases quicker. WL dropout rates were more similar between exception status groups post-policy and non-exception transplant rates increased, allowing non-exception candidates with higher medical urgency to receive transplants while driving down scores at which exception candidates access transplant.

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