Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity.
Treatment: Wedge liver biopsy.
The insurer denied coverage for a wedge liver biopsy.
The denial is upheld.

The patient has a body mass index (BMI) of 54.08 and underwent a laparoscopic Roux-en-Y gastric bypass with a wedge liver biopsy when an enlarged fatty liver was noted at the time of surgery. Obesity is a known risk factor for nonalcoholic fatty liver disease (NAFLD), with a prevalence of 78 to greater than 90 percent in patients undergoing bariatric surgery. There are currently no national guidelines or protocols that support performance of routine liver biopsy in bariatric surgery. Bariatric surgery has also been demonstrated to be very effective in improving or even resolving NAFLD in morbidly obese patients. Therefore, the wedge liver biopsy performed during this patient's robotic-assisted laparoscopic Roux-en-Y gastric bypass was not medically necessary and not supported by review of the current literature. 

The health care plan acted reasonably, with sound medical judgement, and in the best interest of the patient. The patient has a height of 65 inches and a weight of 325 pounds a resulting BMI of 54.08. She underwent a laparoscopic Roux-en-Y gastric bypass. Intraoperatively, the liver was noted to be large and fatty, and a wedge liver biopsy was also performed. Pathology showed marked macrovesicular steatosis and steatohepatitis with minimal activity without fibrosis. The physician, in his appeal letter, explained that their surgical group's policy of performing a liver biopsy "when fatty/enlarged liver is observed at the time of surgery informs us as medical providers on how to monitor this patient. This leads to appropriate follow-up care." The wedge liver biopsy performed on is not considered medically necessary.

Barbois et al noted that nonalcoholic fatty liver disease (NAFLD) is a metabolic complication of obesity encompassing a spectrum from hepatic steatosis, nonalcoholic steatohepatitis (NASH), cirrhosis, to end-stage liver disease.  Noninvasive markers exist, although hepatic histologic evaluation remains the gold standard for diagnosis. In this systemic review, the authors examined the prevalence of NASH in patients with obesity undergoing bariatric surgery, the performance of noninvasive markers of NASH, and the complications of intraoperative liver biopsy. Each noninvasive marker alone was unable to discriminate between patients with a normal liver and those patients with NAFLD. Intraoperative biopsy was related to some complications. These authors concluded that additional prospective studies would be needed to develop an algorithm based on noninvasive markers for preoperative clinical decision-making to determine the necessity of liver biopsy during bariatric surgery. 

There are currently no national guidelines that support the practice of routine liver biopsies during bariatric surgery. Neuberger et al noted that open wedge liver biopsy is occasionally performed in bariatric surgery, "although its usefulness remains unclear".

Mahawar et al examined the role of routine liver biopsy during bariatric surgery. These authors concluded that existing literature "does not make a compelling case for routine liver biopsy with bariatric surgery. Additional morbidity and cost of this intervention can hence only be justified in trials designed to study the impact of bariatric surgery on NAFLD and NASH".

Based on the above, the medical necessity for a liver biopsy is not substantiated. The insurer's denial is upheld.