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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyModa Health Liver Fibrosis Coverage | OpenPayer
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    CurrentModa HealthPolicy N/A

    Non-invasive Testing for Liver Fibrosis

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    This policy governs Moda Health medical-necessity coverage and prior authorization requirements for non-invasive tests used to detect, stage, monitor, or assess the prognosis of hepatic fibrosis in people with chronic liver disease. It identifies covered indications, experimental or investigational uses, non-medically-necessary timing, required documentation, and applicable billing codes.

    Policy Summary
    PayerModa Health
    PolicyNon-invasive Testing for Liver Fibrosis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNov 1, 2026
    Last ReviewOct 28, 2026
    Next Review DateN/A
    Key ActionSubmit chart notes documenting the patient's history and physical examination, along with pertinent laboratory test results and imaging studies, with the prior authorization request.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≤2/yearMaximum FibroTest-ActiTest/HCV-Fibrosure or transient elastography frequency
    6 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Post-biopsy period during which FibroTest-ActiTest/HCV-Fibrosure and transient elastography are not medically necessary
    4Testing modalities identified as medically necessary for specified indications
    12Listed serum marker tests or biomarker approaches considered experimental or investigational
    5Diagnosis-code groups listed in the appendix

    Medical Necessity and Coverage Criteria

    FibroTest-ActiTest/HCV-Fibrosure

    Covered when all applicable conditions are met:

    All of the following

    • The person has hepatitis C or another chronic liver disease, such as hereditary hemochromatosis, and testing is used to distinguish hepatic cirrhosis from non-cirrhosis.
    • Testing is performed no more than two times per year.No more than 2 times per year
    • Testing is not performed within 6 months after a liver biopsy.More than 6 months after liver biopsy

      Testing within 6 months after a liver biopsy is not medically necessary.

    Transient Elastography

    Covered when all applicable conditions are met:

    All of the following

    • The person has hepatitis C or another chronic liver disease, including hereditary hemochromatosis, nonalcoholic fatty liver disease (NAFLD), or nonalcoholic steatohepatitis (NASH), and testing is used to distinguish hepatic cirrhosis from non-cirrhosis.
    • Testing is performed no more than two times per year.No more than 2 times per year
    • Testing is not performed within 6 months after a liver biopsy.More than 6 months after liver biopsy

      Testing within 6 months after a liver biopsy is not medically necessary.

    Magnetic Resonance Elastography

    Covered for the specified indication:

    All of the following

    • Magnetic resonance (vibration) elastography of the liver is used in a person with nonalcoholic steatohepatitis (NASH) for detection and prognosis of liver fibrosis.
    • The service is not used to distinguish hepatic cirrhosis from non-cirrhosis in a person with hepatitis C or another chronic liver disease, and is not used for another indication considered experimental or investigational by this policy.

      MRE is experimental or investigational for distinguishing hepatic cirrhosis from non-cirrhosis in persons with hepatitis C or other chronic liver diseases and for all other indications.

    Enhanced Liver Fibrosis (ELF) Test

    Covered for the specified indication:

    The Enhanced Liver Fibrosis (ELF) test is used for detection and prognosis of liver fibrosis in a person with a chronic liver disease.

    Experimental or Investigational Services

    Not covered as medically necessary:

    Any of the following experimental or investigational services or uses

    • Acoustic Radiation Forced Impulse (ARFI) is used to distinguish hepatic cirrhosis from non-cirrhosis in a person with hepatitis C or another chronic liver disease, or is used for another indication.

      Effectiveness has not been established for these indications.

    • Hepatic Artery Resistance Index is used to evaluate fibrosis progression in an individual with nonalcoholic fatty liver disease (NAFLD).

      Effectiveness has not been established for this indication.

    • A serum marker test is used to detect or monitor hepatic fibrosis in a person with hepatitis C or another chronic liver disease, such as NAFLD.

      Examples include angiotensin converting enzyme, FibroMAX, FibroSpect, HepaScore, LIVERFAST, micro-fibrillar associated glycoprotein 4 (MFAP4), MicroRNA-21, miR-29a, miR-122, miRNA-221, miRNA-222, NASH FibroSure, plasma cytokeratin-18, and signal-induced proliferation associated 1 like 1 (SIPA1L1). This is not an all-inclusive list.

    FibroTest-ActiTest/HCV-Fibrosure and transient elastography performed within 6 months after a liver biopsy are not medically necessary. This timing restriction applies even when the test would otherwise be used to distinguish hepatic cirrhosis from non-cirrhosis in a person with hepatitis C or another chronic liver disease.

    Magnetic resonance elastography (MRE) is considered experimental or investigational when used to distinguish hepatic cirrhosis from non-cirrhosis in persons with hepatitis C or other chronic liver diseases. MRE is medically necessary for the detection and prognosis of liver fibrosis in persons with non-alcoholic steatohepatitis (NASH), but not for this cirrhosis-versus-non-cirrhosis indication.

    Acoustic Radiation Forced Impulse (ARFI) is experimental or investigational for distinguishing hepatic cirrhosis from non-cirrhosis in persons with hepatitis C or other chronic liver diseases and for all other indications. Hepatic Artery Resistance Index is experimental or investigational for evaluating fibrosis progression in individuals with NAFLD. The listed serum marker tests are experimental or investigational for detecting or monitoring hepatic fibrosis, including angiotensin converting enzyme, FibroMAX, FibroSpect, HepaScore, LIVERFAST, MFAP4, MicroRNA-21, miR-29a, miR-122, miRNA-221, miRNA-222, NASH FibroSure, plasma cytokeratin-18, and SIPA1L1.

    FibroTest-ActiTest/HCV-Fibrosure and transient elastography performed within 6 months after a liver biopsy are not medically necessary. Transient elastography, such as Fibroscan, and FibroTest-ActiTest/HCV-Fibrosure may otherwise be medically necessary for specified chronic liver disease indications when used to distinguish hepatic cirrhosis from non-cirrhosis.

    FibroTest-ActiTest/HCV-Fibrosure and transient elastography should be performed no more than two times per year. Testing performed more frequently than this is not medically necessary.

    Billing Codes and Operational Limits

    Covered CPT or HCPCS CodesCPTCovered
    82977Glutamiltransferase, gamma (GGT)
    76391Magnetic resonance (e.g. vibration) elastography
    76981Ultrasound, elastography, parenchyma (e.g., organ)
    76981Liver elastography, mechanically induced shear wave (e.g., vibration) without imaging, with interpretation and report
    81517Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years
    Covered CPT or HCPCS CodesCPTCovered
    47000Biopsy of liver, needle, percutaneous
    47001Biopsy of liver, needle, when done for indicated purpose at time of other major procedure (List separately in addition to code for primary procedure)
    47100Biopsy of liver, wedge
    CPT or HCPCS Codes NOT coveredCPTNot Covered
    83520Immunoassay, analyte, quantitative, not otherwise specified [if billed for FIBROspect or HCV-FIBROSURE, FibroMAX, HepaScore]
    83883Nephelometry, each analyte not elsewhere specified [if billed for FIBROspect or HCV-FIBROSURE FibroMAX, HepaScore]
    88342Immunohistochemistry or Immunocytochemistry, per specimen; initial single antibody stain procedure [for the evaluation of non-alcoholic fatty liver disease and other liver disease] verify coverage for this code
    Applicable Diagnosis CodesICD-10
    B18.0-B18.9Chronic viral hepatitis B
    B19.10Unspecified viral hepatitis B without hepatic coma
    B19.20Unspecified viral hepatitis C without hepatic coma
    E83.110Hereditary hemochromatosis
    K70.0-K77Diseases of the liver (chronic)
    Z94.4Liver transplant status
    Testing Frequency
    Test frequencyNo more than two times per year
    Tests covered by this limitFibroTest-ActiTest/HCV-Fibrosure and transient elastography
    Applicable useDistinguishing hepatic cirrhosis from non-cirrhosis in persons with hepatitis C or other chronic liver diseases
    Interval After Liver Biopsy
    Post-biopsy intervalWithin 6 months after a liver biopsy
    Medical-necessity statusFibroTest-ActiTest/HCV-Fibrosure and transient elastography performed during this interval are not medically necessary

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Submit clinical records and test results

    Prior authorization requests must include chart notes documenting the patient's history and physical examination, along with pertinent laboratory test results and imaging studies.

    Documentation Required

    Include history and physical documentation

    Submit chart notes and documentation of the patient's history and physical examination with the prior authorization request.

    Documentation Required

    Include laboratory and imaging documentation

    Submit pertinent laboratory test results and imaging studies with the prior authorization request.

    Clinical Background

    Hepatic fibrosis is progressive scarring resulting from chronic liver injury. Causes identified in this policy include hepatitis B or C, alcohol-related disease, nonalcoholic fatty liver disease, and other chronic liver diseases. Fibrosis may progress to cirrhosis, and non-invasive serum biomarker panels and imaging-based elastography can help detect or assess significant fibrosis without the need for liver biopsy.

    Key Definitions

    Hepatic Fibrosis
    DefinitionExcessive accumulation of fibrotic connective tissue resulting from prolonged inflammation and progressive scarring of the liver
    Underlying processA sustained wound-healing response to alcohol or non-alcohol-induced liver injury
    Effect on the liverIncreased fibrosis and liver stiffness reduce blood flow through the liver, leading to hardening and death of liver cells
    Significant Fibrosis
    Significant fibrosis stagesF2-F4
    No or minimal fibrosis stagesF0-F1
    Clinical distinction
    Policy Summary
    PayerModa Health
    PolicyNon-invasive Testing for Liver Fibrosis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateNov 1, 2026
    Last ReviewOct 28, 2026
    Next Review DateN/A
    Key ActionSubmit chart notes documenting the patient's history and physical examination, along with pertinent laboratory test results and imaging studies, with the prior authorization request.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaBilling Codes and Operational LimitsPrior Authorization and Documentation RequirementsClinical BackgroundKey Definitions
    Affected testsFibroTest-ActiTest/HCV-Fibrosure and transient elastography
    Denial Risk

    Avoid testing outside frequency, timing, or indication criteria

    FibroTest-ActiTest/HCV-Fibrosure or transient elastography may be denied or considered not medically necessary when testing falls outside the policy criteria.

    • Perform testing no more than two times per year.
    • Do not perform FibroTest-ActiTest/HCV-Fibrosure or transient elastography within 6 months after a liver biopsy.
    • Use these tests to distinguish hepatic cirrhosis from non-cirrhosis in persons with hepatitis C or another covered chronic liver disease.
    Denial Risk

    Confirm the indication before requesting experimental or investigational tests

    MRE, ARFI, hepatic artery resistance index, and the listed serum marker tests may be denied as experimental or investigational when used for indications not established as medically necessary by the policy.

    • MRE is medically necessary for detection and prognosis of liver fibrosis in persons with NASH; other indications are experimental or investigational.
    • ARFI is experimental or investigational for distinguishing cirrhosis from non-cirrhosis in hepatitis C or other chronic liver diseases and for all other indications.
    • Hepatic Artery Resistance Index is experimental or investigational for evaluating fibrosis progression in NAFLD.
    • The listed serum marker tests are experimental or investigational for detecting or monitoring hepatic fibrosis in hepatitis C or other chronic liver diseases.
    Prior Authorization

    Complete all prior authorization documentation

    Prior authorization requests may be denied or delayed when required clinical documentation is missing. Include chart notes, documentation of the patient's history and physical examination, pertinent laboratory test results, and imaging studies.

    Non-invasive panels are evaluated for their ability to differentiate significant fibrosis (F2-F4) from no significant or minimal fibrosis (F0-F1)
    Transient Elastography
    DefinitionAn ultrasound-based, non-invasive examination of liver stiffness
    Also calledFibroscan or vibration-controlled transient elastography
    Policy exampleTransient elastography is medically necessary for specified chronic liver disease indications when used to distinguish hepatic cirrhosis from non-cirrhosis