Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bariatric surgery
Treatment: Laparoscopic procedure (liver biopsy)
The insurer denied the Laparoscopic procedure (liver biopsy).
The denial is upheld.

The patient is a female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that she had a body mass index (BMI) of 58. The operative dictation states that the surgeon observed an enlarged liver with findings compatible with cirrhosis. A wedge liver biopsy was obtained from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provided the diagnosis of no significant pathologic findings of the liver biopsy.

The surgeon submitted Current Procedural Terminology (CPT) code 47100 (liver biopsy, wedge). The health plan rationale for denial of coverage for liver biopsy per the letter is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter, guidelines on the use of liver biopsy in clinical practice do not mention routine biopsy of the liver with bariatric surgery. Appeal material is provided by a surgical partner of the patient's surgeon.

No, the laparoscopic procedure (liver biopsy) was not medically necessary.
The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed by the surgeon. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy. While the surgeon describes an enlarged and cirrhotic liver in the operative dictation, the pathology report states that there was no significant pathologic findings of the liver biopsy.

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.

In this case, the patient is morbidly obese with a body mass index of 58. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. While the operative dictation does describe an enlarged liver per the surgeon, this is not substantiated by preoperative clinical data or by the biopsy report. [1, 2, 3]

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan acted reasonably with the determination of medical necessity regarding liver biopsy in this case.  Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology).  In this case there is no such documentation to warrant wedge liver biopsy (47379 liver biopsy, wedge).