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 45.87 and underwent a robotic-assisted laparoscopic Roux-en-Y gastric bypass with an intraoperative wedge liver biopsy when a 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 operative note stated that there was evidence of a fatty liver, which prompted the performance of a wedge liver biopsy. The prevalence of non-alcoholic fatty liver disease is very common in patients undergoing bariatric surgery upon review of the current literature. The patient had no documentation of elevated liver enzymes or an enlarged liver upon pre-operative imaging to warrant performance of a routine liver biopsy during bariatric surgery. The decision to deny coverage of the wedge liver biopsy for lack of medical necessity is thus in accordance with the current literature.

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. 

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".

Fakhry et al performed a systematic review and meta-analysis to assess the effect of bariatric surgery on the resolution of NAFLD. Twenty-one studies including 2374 patients were examined. Eighty-eight percent (%) of patients demonstrated improvement of steatosis, steatohepatitis improved in 59%, and fibrosis improved or resolved in 30% of patients. These authors concluded that "bariatric surgery should be considered as a treatment of NAFLD."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a wedge liver biopsy is upheld. Medical necessity is not substantiated.