Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: M-79-002
Topic: Noninvasive Techniques for the Evaluation and Monitoring of Patients with Chronic Liver Disease
Section: Diagnostic Medical
Effective Date: November 27, 2017
Issue Date: August 6, 2018
Last Reviewed: July 2018

Liver elastography, also known as shear wave elastography, is a novel and non-invasive technology for assessing tissue stiffness used in the evaluation of fibrosis or cirrhosis in patients with chronic liver disease. 

These specialized methods, which are an alternative to liver biopsy, include transient elastography (e.g., FibroScan), magnetic resonance elastography (MRE), acoustic radiation force impulse imaging (ARFI; e.g., Acuson S2000), and real-time tissue elastography (RTE; e.g., HI VISION Preirus).

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Transient elastography (FibroScan) imaging may be considered medically necessary for the evaluation of patients with chronic liver disease.

Transient elastography (FibroScan) imaging is considered not medically necessary when performed within six (6) months following a liver biopsy.

Transient elastography (FibroScan) imaging for monitoring of patients with chronic liver disease at less than two (2) year intervals is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

The use of other noninvasive imaging, including but not limited to MRE, ARFI (e.g., Acuson S2000), or RTE (e.g., HI VISION Preirus) for the evaluation or monitoring of patients with chronic liver disease, is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes
91200


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Transient elastography is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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