Background <p>Liver transplantation (LT) for unresectable colorectal liver metastases (CRLM) was historically dismissed as the 5-year overall survival was as low as 18%. However, more recently, in carefully selected patients, LT has re-emerged as a viable treatment and possibly curative treatment option. The implementation of the Model for End-Stage Liver Disease (MELD) exception criteria for patients with CRLM warrants a careful evaluation of selection criteria and outcomes, given the shift in transplant allocation policies.</p> Methods <p>This review evaluates literature published between 2020 and 2025 on LT for unresectable CRLM, focusing on patient selection criteria, transplant outcomes, and updates to the Model for End-Stage Liver Disease (MELD) exception criteria for CRLM.</p> Results <p>Over the last several years, clinical evidence primarily from the SECA II and TRANSMET trials have demonstrated a profound survival benefit for LT in highly selected CRLM patients. The TRANSMET trial demonstrated a 73% 5-year overall survival (OS) rate compared to 9% with chemotherapy alone. This OS is comparable to other established indications for general LT. Patient selection factors include primary tumor R0 resection, absence of extrahepatic disease, favorable molecular markers (microsatellite stable tumor, BRAF wild type), and response to systemic chemotherapy prior to LT.</p> Conclusions <p>Liver transplantation in carefully selected patients with unresectable CRLM is a viable treatment option that can significantly extend life expectancy. The new MELD exception policies provide an avenue for more patients to obtain a LT and can improve outcomes in highly selected CRLM patients. With many upcoming clinical trials, future directions should emphasize the refinement of patient selection, the adoption of standardized criteria, the optimization of pre- and post-transplant treatment, and the collection of robust data through national and international registries.</p>