Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity.
Treatment: Liver biopsy.
The insurer denied coverage for a liver biopsy.
The denial is upheld.

This patient has a history of morbid obesity, hypertension, and liver disease. The patient's body mass index (BMI) measured 47.78. He meets the National Institute of Health (NIH) criteria for weight loss surgery. The surgeon noted findings of central visceral obesity, fatty liver. A liver biopsy was performed as noted by the pathology report generated from a specimen, however, there is no mention in the operative report of a biopsy. A robotic sleeve gastrectomy was performed.  Pathology revealed minimal fatty change with no steatohepatitis, bridging fibrosis or cirrhosis. 

Several articles were included in the provider package. Aminian et al (4) concluded that "Among patients with NASH (nonalcoholic steatohepatitis) and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and MACE (major adverse cardiovascular events)."

 A second reference included was Shalhub et al (8) who 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 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."  This paper was published years ago, and it is not the standard now to biopsy without cause at the time of bariatric surgery. 

Other literature reviewed included Sheth (1) who noted that "while liver biopsy is the gold standard for diagnosing NAFLD [non-alcoholic fatty liver disease], 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."

There was no indication that the patient had any noninvasive evaluation to indicate NASH. Fibroscan shows good diagnostic accuracy in detecting advanced stage and grade of NAFLD. Yang et al (3) reported that fibroscan can be performed reliably in bariatric cohorts and is useful at baseline and follow-up.

A paper by Jones et al (5) reported a retrospective review of adolescents who received bariatric surgery at their institution over a period of time. In years past, all patients routinely received intraoperative liver biopsy. More recently, 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."  

Based upon the information provided, review of the literature and articles that the provider referenced, liver biopsy at the time of this bariatric surgery was not indicated. 

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

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