Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wedge liver biopsy

The insurer denied coverage for wedge liver biopsy.
The denial is upheld.
	
The patient has a history of obesity, diabetes, and hypertension. She has suffered from severe obesity her entire adult life. She cannot control her weight with diet and exercise and has met National Institute of Health (NIH) criteria for bariatric surgery with a body mass index (BMI) of 36 and comorbid conditions of diabetes and hypertension. It should be noted that limited records were provided. She underwent laparoscopic roux en y gastric bypass and wedge liver biopsy.  There was no mention of liver abnormalities otherwise. Path revealed moderate steatosis on liver biopsy. The patient was discharged.

Based upon the information provided, wedge liver biopsy at the time of this bariatric surgery was not indicated. This is based upon review of the literature and even based upon the articles that the provider referenced. The provider referenced the following articles. Mahawar et al "Routine Liver Biopsy During Bariatric Surgery: An Analysis of Evidence Base" in  Obes Surg. 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 provider also referenced Aminian et al "Association of Bariatric Surgery with Major Adverse Liver and Cardiovascular Outcomes in Patients with Biopsy-Proven Nonalcoholic Steatohepatitis"  JAMA. The authors concluded in their paper "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 cardiac events]."   Finally, the provider referenced Shalhub et al who noted in " The importance of routine liver biopsy in diagnosing nonalcoholic steatohepatitis in bariatric patients" in Obes Surg 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 recommend "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." The provider referenced this paper --however, it should be noted that this paper was published several years ago, where now the standard is not to biopsy without cause at the time of bariatric surgery as noted by Mahawar in the paper noted above. 

In addition, Sheth noted in  UpToDate "Epidemiology, clinical features, and diagnosis of nonalcoholic fatty liver disease in adults",  that "while liver biopsy is the gold standard for diagnosing NAFLD [nonalcoholic 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 except for the observation at the time of the surgery. In addition, the author noted that "a potentially useful non-invasive method for excluding advanced fibrosis is measurement of liver stiffness with transient elastography." Thus, given the more recent  literature such as UpToDate and Jones et al 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 wedge liver biopsy rendered is not substantiated. The insurer's denial is upheld.