Diagnosis: Endocrine/Metabolic/Nutritional/Obesity
Treatment: Surgical Services
The health plan denied the requested liver biopsy as not medically necessary.
The health plan's determination is upheld.

This patient is a female who underwent laparoscopic Roux-en-Y gastric bypass. The patient's liver was noted to be fatty infiltrated, and a wedge liver biopsy was performed during the procedure. Findings of moderate macrovesicular steatosis was found.

At issue is the medical necessity of the liver biopsy performed.

The health plan's determination of medical necessity is upheld.

Routine liver biopsy, in particular, wedge liver biopsy during bariatric surgery has not been documented in any prospective or high-level study to be medically necessary. National guidelines from American Society for Metabolic and Bariatric Surgery (ASMBS) to support routine liver biopsy are not available at this time.

Non-alcoholic steatohepatitis (NASH)/non-alcoholic fatty liver disease (NAFLD) are common conditions associated with morbid obesity and grossly, some element of fatty liver can be seen in a majority of patients undergoing bariatric surgery. The benefit of routine liver biopsy, however, without a preoperative diagnostic finding or clinical concern of NASH or a plan to follow with a biopsy at an interval time to assess the progression of disease has not been documented in any high-level prospective study. Separately, liver biopsy for evaluation of steatosis/fibrosis are best performed through a core needle or tru-cut biopsies which provide long cylindrical cores of liver parenchyma approximately 1 to 2 centimeter (cm) in length by approximately 0.2 cm in width. More than one pass as necessary can also be performed. Although a wedge liver biopsy may provide more/larger overall tissue to assess, it is performed on the very edges of the liver, may not capture the full detail of the liver parenchyma as these biopsies are often subcapsular, which may give the false impression of increased fibrosis exaggerating the finding of steatosis (as compared to a core biopsy of the same individual within a more central area of the liver with long cylindrical core).