Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity

Treatment: liver wedge biopsy

The insurer denied coverage for a liver wedge biopsy.

The denial is upheld.

As per the medical records provided, this is a patient with a medical history of asthma, polycystic ovarian disease, and morbid obesity. As per the operative note the patient has attempted multiple diets over the years and has been able to lose modest amount of weight. However, the weight loss has never been sustained. Her body mass index (BMI) was 40.79. The patient underwent Roux en y Gastric bypass. The operative note indicated the liver was evaluated, which looked fatty infiltrated, and a wedge liver biopsy was taken from the left lobe with a Harmonic device. Pathology revealed essentially normal subcapsular liver tissue with minimal steatosis and no evidence of steatohepatitis.

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

In the article by Mahawar et al (5) the authors make the following statement "Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery."  The authors also concluded that "additional morbidity and cost of this intervention can hence only be justified in trials designed to study the impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)."

In an article by Aminian et al (2) the authors concluded that "Among patients with NASH and obesity, bariatric surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident major adverse liver outcomes and major adverse cardiovascular events."  

The article by Shalhub et al. (6) 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 non-alcoholic steatohepatitis (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."  However, this paper was published years ago, and now the standard is not to biopsy without cause at the time of bariatric surgery as noted by Mahawar (5). 

Other literature reviewed included Sheth (1) who noted that "a potentially useful non-invasive method for excluding advanced fibrosis is measurement of liver stiffness with transient elastography."  

Finally, a noteworthy retrospective review on the question of the utility of wedge liver biopsy by Jones et al (3) focused on adolescents who received bariatric surgery at their institution. At one time, all patients routinely received intraoperative liver biopsy. Years later, 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."  Thus, the liver biopsy was not medically necessary.

The health care plan did act reasonably and with sound medical judgment. 

Based on the above, the medical necessity for a liver wedge biopsy is not substantiated. The insurer's denial is upheld.