Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity

Treatment: Liver biopsy

The insurer denied coverage a liver biopsy.

The denial is upheld.

As per the medical records provided, this patient has a history of severe obesity, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), inflammatory disease of the uterus, and thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. The patient had attempted multiple diets over the years and lost a modest amount of weight. However, the weight loss has never been sustained. Her body mass index (BMI) measured 43.4. Her weight impacted her activities of daily living.  She met the National institute of Health (NIH) criteria for weight loss surgery. The operative note indicated a Roux en y Gastric bypass and wedge liver biopsy were performed. The pathology report revealed moderate macro vesicular steatosis. The patient's pre-surgical serologic studies showed normal values for albumin, alkaline phosphatase, total bilirubin, and liver enzymes.

Based on the information provided as well as the literature and articles referenced by the provider, liver biopsy at the time of this bariatric surgery was not indicated. 

In the article by Mahawar et al (7) the authors stated the following "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."  The authors also 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 non-alcoholic steatohepatitis (NASH)."

In an article by Aminian et al (4) the authors 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 major adverse cardiovascular events."  

The article by Shalhub et al (8) 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 non-alcoholic steatohepatitis (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."  However, this paper was published years ago, and now the standard is not to biopsy without cause at the time of bariatric surgery as noted by Mahawar (7). 

Finally, a review on the utility of wedge liver biopsy by Jones et al (5) focused on adolescents who received bariatric surgery at their institution. At one time, all patients routinely received intraoperative liver biopsy. Years later, 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."  Thus, given the more recent literature and the other papers noted above, the liver biopsy was not medically necessary.

The health care plan did act reasonably and with sound medical judgment.  
Based on the above, the medical necessity for the liver biopsy is not substantiated.
The insurer's denial is upheld.