Diagnosis: Digestive System/Gastrointestinal.
Treatment: Surgical Services.

The insurer denied livery biopsy.
The denial is upheld.

The patient is a female who underwent bariatric surgery (laparoscopic roux en Y gastric bypass and concomitant liver biopsy) performed. The records support that she had a body mass index (BMI) of 50 kilograms per square meter (kg/m2). The operative dictation states that a wedge liver biopsy was obtained from the left lobe of the liver. There is no description of suspected liver pathology. The submitted records do not include any pre-surgical lab, imaging, or clinical data to indicate liver pathology. The pathology report provides the diagnosis of moderate steatosis. The health plan rationale for denial of coverage for liver biopsy is that there is no documentation of signs or symptoms of liver disease to warrant liver biopsy. The subject under review is the medical necessity for the liver biopsy.

The health plan's determination is upheld.

The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy.

Accepted indications for liver biopsy include documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy.

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.

In this case the patient is morbidly obese and had hepatic steatosis and moderate steatohepatitis on biopsy. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology. The operative dictation also does not describe specific liver pathology to warrant liver biopsy. The steatohepatitis identified on the biopsy is an anticipated pathologic condition in the setting of morbid obesity and does not mandate biopsy. [1,2]