Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:Nonalcoholic Steatohepatitis and Mass/Lesion in the Liver
Treatment: Magnetic Resonance Imaging (MRI) of the Abdomen
The insurer denied the Magnetic Resonance Imaging (MRI) of the Abdomen.
The determination is upheld.
The patient has a past medical history significant for hypertension, new onset type II diabetes mellitus (DM), hyperlipidemia, hypothyroidism, gastroesophageal reflux disease (GERD), colon polyps, depression, anxiety, Helicobacter (H.) pylori gastritis, vitiligo, arthritis, non-alcoholic steatohepatitis, and focal nodular hyperplasia. She had a hepatic lesion identified as focal nodular hyperplasia. She had developed symptoms of GERD and epigastric discomfort, and subsequently had an esophagogastroduodenoscopy (EGD) and colonoscopy. Her body mass index (BMI) is 34.16. Her aspartate aminotransferase (AST) is 32, alkaline phosphatase 91, calcium 9.6, glucose 178, hemoglobin 14.0, Hgb A1C 8.0. A magnetic resonance imaging (MRI)scan of the abdomen was ordered for follow up of her hepatic lesion and non-alcoholic steatohepatitis (NASH). She has an allergy to contrast and therefore, a CT scan was not ordered. She had an MRI of the abdomen revealing a 1.7 centimeter (cm) indeterminate hepatic lesion in segment 7 which was not typical for a hemangioma or focal nodular hyperplasia. It had arterial enhancement with progressive enhancement of subsequent images. The liver was non-cirrhotic, and there was no evidence of hepatic iron deposition. There was diffuse hepatic steatosis with a proton density fat fraction of 13% (normal is less than [<] 5%). There was also beading and irregularity of the right renal artery. At issue is whether the proposed health service or treatment Magnetic Resonance Imaging (MRI) of the Abdomen is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The MRI of the abdomen was not likely to have been more beneficial than standard treatment for evaluation of the patient's conditions.
The patient had a history of NASH and focal nodular hyperplasia. She did not require an MRI of the abdomen in order to follow up the hepatic lesion which had been thought to have been focal nodular hyperplasia (FNH). She also did not require an MRI of the abdomen for follow up of a history of NASH. An ultrasound may have been performed for evaluation of the hepatic lesion. Follow up of the patient's NASH may have been performed with serologies or a FibroScan.
"The commonly investigated noninvasive tools for the presence of advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) include clinical decision aids (e.g., NAFLD fibrosis score,  fibrosis (FIB)-4 index, aspartate aminotransferase [AST] to platelet ratio index [APRI]), serum biomarkers (Enhanced Liver Fibrosis [ELF] panel, Fibrometer, FibroTest, and Hepascore), or imaging (eg, TE, MR elastography [MRE], acoustic radiation force impulse imaging, and supersonic shear wave elastography)." [1]
"Ultrasound is well accepted worldwide for imaging of the liver. Absences of radiation exposure, low cost and large diffusion are some of the advantages that make this technique the first to be used in the assessment of focal liver lesions (FLL). Contrast enhanced ultrasound (CEUS) is safe and allows an immediate evaluation of the nature of FLL. CEUS permits differentiation between malignant and benign FLL in healthy liver parenchyma by analysing the arterial, portal venous and late phases. Contrast enhanced magnetic resonance imaging (CEMRI) and contrast enhanced computed tomography (CECT) are reliable to characterize FLL but higher costs, radiation exposure, nephrotoxicity (in particular for CECT) and absence of real time imaging limit the appropriate evaluation of FLL. Therefore, CEUS can be preferred in most clinical situations, and when results are unclear or suggestive for malignant FLL, biopsy and histological examination can be directly initiated avoiding unnecessary additional imaging." [3]
"Focal Liver Lesions (FLL) refers to a series of space-occupying lesions including both benign and malignant in the liver. They are usually detected incidentally during an abdominal ultrasound examination." [4]

The health plan's determination is upheld in whole.