Currentblue cross blue shield - tennesseePolicy N/A

Noninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases

This policy defines medical necessity and investigational indications for noninvasive imaging techniques that map liver tissue elasticity (e.g., transient elastography, magnetic resonance elastography, ARFI, multiparametric MRI) for evaluating and monitoring chronic liver disease for BlueCross BlueShield of Tennessee members.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyNoninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 31, 202650d

Next Review DateN/A

Key ActionObtain prior authorization when requesting MRE for assessment of fibrosis and ensure documentation supports that medical appropriateness criteria are met (e.g., chronic liver disease and VCTE unavailable/contraindicated/indeterminate or BMI ≥ 30).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2medically necessary technologies

multipleinvestigational techniques

126articles/guidelines reviewed

7/31/2026policy effective

Coverage and Medical Necessity Criteria

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Medical necessity criteria for VCTE and MRE

Covered when ALL of the following are met for the specified modalities:

Transient elastography (VCTE/FibroScan): Transient elastography imaging (i.e., FibroScan®) when used to evaluate and/or monitor individuals with chronic liver disease is considered medically necessary.

Not considered medically necessary for focal liver disease; focal disease use considered investigational.

Magnetic resonance elastography (MRE): Magnetic resonance elastography is considered medically necessary if the medical appropriateness criteria are met.

See MRE appropriateness subcriteria below.

MRE appropriateness subcriteria: MRE is appropriate when ALL of the following are met: chronic liver disease (defined by ANY ONE of specified conditions) AND need to assess for advanced fibrosis or cirrhosis with any one of: VCTE unavailable/contraindicated/indeterminate OR BMI ≥ 30.

Chronic liver disease examples include metabolic dysfunction-associated steatotic liver disease with known or suspected fibrosis/cirrhosis, or other chronic liver diseases (e.g., chronic hepatitis B or C).

Investigational / Not covered modalities

Investigational modalities: All other noninvasive imaging that maps the elastic properties of soft tissue to evaluate and/or monitor individuals with chronic liver disease are considered investigational. Examples include ARFI (Acoustic radiation force impulse) imaging, multiparametric MRI (e.g., LiverMultiScan), real-time tissue elastography, and alternative transient elastography devices (e.g., Hepatus®, Liverscan C).

Clinical impact on health outcomes not established.

This policy applies to noninvasive imaging techniques that map liver tissue elasticity to evaluate and monitor chronic liver disease. It does not address multianalyte serum assays, standard imaging with ultrasound, or routine MRI studies; those are outside the scope of this policy. Providers should use the specific modality coverage rules in this document when requesting or performing elastography or related noninvasive liver stiffness assessments.

Transient elastography (VCTE/FibroScan®) when used to evaluate and/or monitor individuals with focal liver disease is considered investigational and therefore not medically necessary for that indication. Requests for VCTE to assess focal liver lesions or focal hepatic disease processes should be denied as investigational.

Indications for Covered Modalities

Indications for Magnetic Resonance Elastography

MRE indication: Chronic liver disease, as indicated by ANY ONE of the following: metabolic dysfunction-associated steatotic liver disease with hepatic fibrosis or cirrhosis known or suspected; OR other chronic liver disease (e.g., chronic hepatitis B or C) when there is a need to assess for advanced fibrosis or cirrhosis and VCTE is unavailable, contraindicated, or results are indeterminate; OR BMI ≥ 30.BMI ≥ 30

Indications for Transient Elastography

VCTE indication: Use of transient elastography (FibroScan®) to evaluate and/or monitor individuals with chronic liver disease is considered medically necessary.

Not indicated for focal liver disease.

Provider Requirements, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization Expectations

Prior authorization may be required for imaging studies that are subject to this Medical Policy. Providers should verify benefit coverage and obtain any required authorizations before scheduling Magnetic Resonance Elastography (MRE) or Vibration-Controlled Transient Elastography (VCTE).

Prior authorization expectations apply when Medical Policy determinations govern coverage.
If prior authorization is required by the member's benefit plan, approval should be obtained in advance.

Note

Preferred Initial Modality

Vibration-controlled transient elastography (VCTE) is the preferred initial noninvasive modality to assess hepatic fibrosis. Magnetic resonance elastography (MRE) is preferred when VCTE is unavailable, contraindicated, or when VCTE results are indeterminate.

Use VCTE (e.g., FibroScan®) as first-line assessment for chronic liver disease when available and appropriate.
Use MRE when VCTE is not feasible, contraindicated, or yields indeterminate results; or when clinical circumstances warrant MRE per Medical Appropriateness criteria.

Documentation Required

Documentation for MRE

When requesting Magnetic Resonance Elastography (MRE), submit documentation that supports medical appropriateness. Include clinical information demonstrating chronic liver disease and why MRE is indicated (for example, VCTE unavailability, contraindication, indeterminate result, or BMI ≥ 30).

Clinical history documenting chronic liver disease (e.g., metabolic dysfunction-associated steatotic liver disease, chronic hepatitis B or C, or other chronic liver conditions).
Reason MRE is requested instead of VCTE: VCTE unavailable, contraindicated, or indeterminate.
Relevant measurements or findings (e.g., prior VCTE results if performed, BMI ≥ 30 when applicable).
Any prior imaging or laboratory data that supports need to assess for advanced fibrosis or cirrhosis.

Denial Risk

Investigational Modality Denial Risk

Requests for modalities that are listed as investigational in this policy may be denied. Examples include noninvasive elastography technologies other than VCTE and MRE (for example, acoustic radiation force impulse imaging, multiparametric MRI such as LiverMultiScan, real-time tissue elastography).

Requests for transient elastography to evaluate focal liver disease may be denied as investigational.
Requests for other noninvasive elastography technologies not supported by the policy may be denied.

Definitions of Modalities and Terms

Transient elastography (VCTE/FibroScan)

DefinitionVibration-controlled transient elastography (VCTE/FibroScan): a mechanical vibrator generates low-frequency (≈50 Hz) shear waves that propagate through the liver; shear-wave velocity is measured to estimate liver stiffness (degree of fibrosis).

MechanismShear waves produced by an external mechanical vibrator travel through liver tissue; faster shear-wave velocity corresponds to increased tissue stiffness, which is quantified (kPa) to assess fibrosis.

Variants/DevicesIncludes FibroScan®; other transient elastography devices (e.g., Hepatus®, Liverscan C) combine transient elastography with ultrasound guidance and additional attenuation metrics for steatosis assessment.

ARFI (pSWE, 2D‑SWE)

DefinitionAcoustic radiation force impulse (ARFI): an ultrasound probe delivers an acoustic 'push' pulse that generates shear waves in tissue to assess local liver stiffness.

VariantsQualitative ARFI — images localized tissue displacement without numeric stiffness values; Quantitative ARFI — measures shear-wave speed, convertible to stiffness (includes point shear-wave elastography [pSWE] and two-dimensional shear-wave elastography [2D‑SWE]).

ScopePermits evaluation within a localized region; implemented on multiple vendor platforms (examples listed in policy).

Magnetic resonance elastography (MRE)

DefinitionMagnetic resonance elastography (MRE): combines MRI imaging with applied waves to create a visual map (elastogram) that shows tissue stiffness across the liver.

MechanismLow-frequency mechanical waves are transmitted into the liver during MRI acquisition; the resulting wave propagation is imaged and processed to produce an elastogram quantifying tissue stiffness.

OutputProduces an elastogram — a spatial map of liver stiffness used to assess and stage hepatic fibrosis.

Multiparametric MRI (MMRI / LiverMultiScan)

DefinitionMultiparametric MRI (MMRI; e.g., LiverMultiScan): an MRI-based approach combining quantitative assessments of hepatic fat (steatosis) with T1 and T2 relaxation mapping to evaluate tissue characteristics related to fibrosis, inflammation, and iron content.

ComponentsSteatosis assessment (hepatic fat fraction) plus T1 mapping (reflects extracellular fluid increases associated with fibrosis and inflammation) and T2 mapping (used to assess hepatic iron content).

PurposeIntegrates multiple MRI-derived metrics to characterize liver tissue beyond stiffness alone, aiming to evaluate steatosis, fibrosis-related changes, inflammation, and iron deposition.

Not Covered / Investigational Services

The following noninvasive modalities that map elastic properties of liver tissue are considered investigational and are not covered: acoustic radiation force impulse (ARFI) imaging (e.g., Acuson S2000), multiparametric MRI (e.g., LiverMultiScan), real‑time tissue elastography (e.g., HI VISION Preirus™), and alternative transient elastography devices not specified as FibroScan® (for example devices such as Hepatus® or Liverscan C). Clinical impact on health outcomes for these techniques has not been established.

Background and Rationale

Noninvasive elastography techniques offer alternatives to liver biopsy by estimating tissue stiffness as a proxy for fibrosis. Common modalities include transient elastography (VCTE/FibroScan®) and magnetic resonance elastography (MRE), with evidence strongest for those two methods. Other approaches (for example ARFI, real‑time tissue elastography, and multiparametric MRI) have more limited supporting evidence. Use of MRE or VCTE should follow the medical appropriateness criteria in this policy to ensure the test addresses chronic liver disease assessment or monitoring rather than focal liver disease or investigational uses.