Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-alcoholic steatohepatitis

Treatment: Laparoscopic procedure (CPT [current procedure terminology] 47379)

The insurer denied coverage for laparoscopic procedure (CPT 47379).

The denial is upheld.

The patient is a female with a history of arthritis, gastric ulcer, hypertension, hypothyroidism, multiple sclerosis, morbid obesity, stomach surgery, lap gastric band, revision of lap band and a slipped band. Currently she has a weight of 236 pounds and wants the band out and revised to Roux-en-Y gastric bypass. The operative note indicated the patient underwent lap removal of lap band, conversion to Roux en y gastric bypass, liver wedge biopsy, and lysis of adhesions. The indications note that a wedge live biopsy may be done if there is a fatty liver. The operative note indicates that the patient had a fatty liver and the surgeon opted to proceed to take a wedge liver biopsy with Harmonic scalpel. Pathology revealed mild steatosis on liver biopsy. The patient was discharged.

It should be noted that if a laparoscopic biopsy of the liver is performed at the same time as another laparoscopic procedure, the provider is to report unlisted current procedure terminology (CPT) code 47379, as there is no CPT code for a laparoscopic liver biopsy. The biopsy was not indicated. This is based upon review of the literature and the articles that the provider referenced. 

For example, according to Sheth in UpToDate 2021 "Epidemiology, clinical features, and diagnosis of nonalcoholic fatty liver disease in adults", "While liver biopsy is the gold standard for diagnosing nonalcoholic fatty liver disease (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. However, some patients will continue to have an unclear diagnosis following a noninvasive evaluation. In such cases, a liver biopsy is indicated." There was no indication that the patient had any noninvasive evaluation to indicate NASH (non-alcoholic steatohepatitis), except for the observation at the time of the surgery that the patient may have had a fatty liver. In addition, the author noted that "a potentially useful non-invasive method for excluding advanced fibrosis is measurement of liver stiffness with transient elastography."  

Jones, et al recently noted and raised the specific question of "Intraoperative Liver Biopsy during Adolescent Bariatric Surgery: Is It Really Necessary?" in Obesity Surgery 2020. They did a retrospective review of adolescents who received bariatric surgery. 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. Prospective, longitudinal studies are needed to better understand the meaningfulness of liver histopathology in this population." Thus, given the more recent literature, the liver biopsy was not medically necessary.

Based upon the records provided, the patient did not need a liver biopsy. 

The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for the laparoscopic procedure (CPT 47379) is upheld. Medical necessity is not substantiated.