Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type B viral hepatitis
Treatment: CT scan
The insurer denied
The determination is upheld.

The patient has a medical history significant for gastroesophageal reflux disease (GERD), nephrolithiasis, and Hepatitis B virus [HBV]. His aspartate aminotransferase (AST) is 38, alanine aminotransferase (ALT) 51, alkaline phosphatase 82, total bilirubin 0.5, alpha-fetoprotein (AFP) 3.4, hepatitis B e-antigen (HBeAg) negative, HBV deoxyribonucleic acid (DNA) 986. His body mass index (BMI) is 28. He had an ultrasound [11/22/19] revealing a heterogenous, slightly nodular liver, questionable cirrhosis. A CT scan was ordered to further evaluate the liver. At issue is the medical necessity of the CT scan.

The CT scan is not medically necessary. The patient has hepatitis B [HBV] and had an ultrasound revealing a slightly nodular liver, questionable for cirrhosis. A CT scan was not medically necessary in order to determine the presence of cirrhosis for this patient and is not standard of care. The CT scan will not give a fibrosis score which is required to determine the extent of fibrosis of the liver.
The medical standard of care for determining the presence of cirrhosis includes non-invasive methods of fibrosis determination such as ultrasound elastography or serological testing or in some cases, a liver biopsy which is considered the gold standard for determination of fibrosis or cirrhosis. Tests such as ultrasound elastography, or serological assays for fibrosis [FibroTest, FibroSure, etc], or a liver biopsy [the gold standard] will give more accurate representations of the degree of fibrosis which a CT scan cannot. 
"In a combined analysis of data from 2 large studies, we found that fibrosis (FIB)-4, aspartate aminotransferase to platelet ratio index (APRI), and non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS) can detect advanced fibrosis and fibrosis progression in patients with  NAFLD." [1].
"The etiology of liver disease and clinical context should be taken into consideration when non-invasive markers are incorporated in clinical practice. Non-invasive assessment of fibrosis has been most extensively utilized in hepatitis C, followed by hepatitis B and nonalcoholic fatty liver disease, but its role remains less developed in other etiologies of liver disease such as alcohol-associated liver disease and autoimmune liver disease." [2].
"Of the 1673 patients, 104 developed cirrhosis after a mean follow-up of 15.9 years. Higher hepatitis B core-related antigen (HBcrAg) levels were associated with increased incidence of cirrhosis, cirrhosis-related complications, and liver-related death. In 445 patients with intermediate viral load, the cirrhosis risk stratified by HBcrAg level of 10 kilounit per milliliter (KU/mL) yielded a hazard ratio of 3.22 (95% confidence interval (CI): 1.61-6.47). The risk stratification remained significant when exploring other pre-cirrhosis endpoints, including HBeAg-negative hepatitis, hepatitis flare, and HBV deoxyribonucleic acid (DNA) greater than (>) 20 000 international units per milliliter (IU/mL) after 3 years of follow-up. In HBeAg-negative patients with normal alanine aminotransferase (ALT) levels, higher HBcrAg levels are associated with increased risk of cirrhosis. Among those with intermediate viral load, HBcrAg less than (<) 10 KU/mL defines a low-risk group for disease progression." [3]
"The risk of liver-related complications is variable and influenced by a variety of host, viral, and environmental factors. Determining the stage of liver disease (e.g., evidence of inflammation, fibrosis) is important to guide therapeutic decisions and the need for hepatocellular carcinoma (HCC) screening. Although liver biopsy is recommended for assessing inflammatory activity and fibrosis, noninvasive tests, such as transient elastography or a serum fibrosis panel, are also useful." [4].
"Staging of liver disease severity using liver biopsy or noninvasive tests such as elastography are important in guiding surveillance and assisting with treatment decisions." [5]