Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity

Treatment: laparoscopic procedure (CPT [Current Procedural Terminology] 47379)

The insurer denied coverage for laparoscopic procedure (CPT 47379)

The denial is upheld

This is a patient with a history of asthma, hypertension, hyperlipidemia, and morbid obesity.  The patient has a body mass index (BMI) of 37.9. She meets the National Institute of Health (NIH) criteria for weight loss surgery. The surgeon's operative note indicated a Roux en y Gastric bypass was performed and a wedge biopsy was obtained from the left lobe of the liver. Pathology revealed mild to moderate steatosis with no significant inflammatory component, fibrosis, or hepatocellular degenerative changes.

Based upon the information and literature provided, the liver biopsy at the time of this bariatric surgery was not indicated. Mahawar et al (7) stated "Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery."  This paper noted that existing scientific literature does not make a compelling case for routine liver biopsy with bariatric surgery. The authors concluded that "additional morbidity and cost of this intervention can hence only be justified in trials designed to study the impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)." 

Another article referenced by the provider by Aminian et al (4) concluded that "Among patients with NASH and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and MACE (major adverse cardiovascular events)." 

The last article included by the provider was by Shalhub et al (8) who noted that "Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH." They recommended "routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures."  This paper was published years ago, and it is not the standard now to biopsy without cause at the time of bariatric surgery. 

Other literature reviewed included Sheth (1) who noted that "while liver biopsy is the gold standard for diagnosing NAFLD, in many cases a presumptive diagnosis can be made based upon the patient's history, laboratory tests, and imaging findings, provided other disorders have been excluded." There was no indication that the patient had any noninvasive evaluation to indicate NASH except for the observation at the time of the surgery (which was not clearly documented in the operative report). 

An additional paper by Jones et al (5) reported a retrospective review of adolescents who received bariatric surgery at their institution over a range of years. In years past, all patients routinely received intraoperative liver biopsy. More recently, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. They concluded that "Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management."  

Based upon the records provided, the patient did not need a liver biopsy. The health care plan did act reasonably and with sound medical judgment. The patient did not meet criteria for routine liver biopsy at the time of bariatric surgery based upon references provided. 

The insurer's denial of coverage for procedure 47379, liver biopsy, is upheld. Medical necessity is not substantiated.