Clinician reference tool — not medical advice. This is a clinical decision-aid intended for healthcare professionals: it gives deterministic suggestions to think with, not a diagnosis or a prescription. If you’re a patient, you’re welcome to look around — but please review anything here with your own doctor; it isn’t a substitute for personalized medical care.
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Liver panel (ALT, AST, GGT, ALP, bilirubin, albumin)

Wellness panel · specimen: blood

Indicated in specific situations

Also called: liver function tests, LFTs, hepatic panel, liver enzymes, liver panel

Chart note

Pick Ordered or Not ordered to see the note.

Indicated when

  • Metabolic risk factors such as obesity, type 2 diabetes, or other features of metabolic syndrome, where a risk-based approach starting with ALT, and a fibrosis risk score such as FIB-4 if ALT is abnormal, is part of current clinical pathways for finding metabolic dysfunction-associated steatotic liver disease [11]
  • Symptoms suggestive of liver disease, such as jaundice, right upper quadrant pain, or dark urine
  • Monitoring a medication known to affect the liver
  • Follow-up of a previously abnormal liver enzyme result, using a hepatocellular versus cholestatic pattern to guide further work-up [10]

Not indicated when

  • Routine annual or 'wellness panel' screening of the full bundle in an asymptomatic adult with no metabolic risk factors, symptoms, or hepatotoxic medication exposure [12]
  • A family physician ordering AST as part of routine screening: AST is OHIP-insured only when ordered by, or on the advice of, a physician with hepatic expertise, so a routine family-physician AST is not an insured service [2]

Why not

Testing several liver enzymes at once in a low-risk, asymptomatic adult increases the chance of an isolated, often transient or clinically insignificant elevation that prompts repeat testing or further work-up without an established benefit in that population [12]. Interpreting an abnormal result also requires knowing the pattern (hepatocellular versus cholestatic) and the clinical context, which an isolated panel ordered without a reason does not provide [10].

Better first step

Start with ALT when there is a reason to check it, such as metabolic risk factors, symptoms, or medication monitoring; if ALT is abnormal, follow a structured evaluation of hepatocellular versus cholestatic pattern rather than reflexively repeating the whole panel [10]. AST should specifically be reserved for use by, or on the advice of, a clinician with hepatic expertise, both because that is what OHIP insures and because AST alone is nonspecific.

Typical ND rationale

An ND may order a full liver panel to get an early, broad look at liver health, reasoning that liver enzymes are inexpensive and can flag fatty liver disease or other liver injury well before symptoms appear.

Where the ND is right

This is a place the ND's underlying instinct has real support: in patients with obesity, type 2 diabetes, or other metabolic risk factors, checking ALT and following an elevated result with a fibrosis risk score such as FIB-4 is consistent with current risk-based clinical pathways for finding metabolic dysfunction-associated steatotic liver disease before it becomes advanced [11]. What is not supported is ordering the entire bundle, including AST, as an undifferentiated annual screen in someone with no metabolic risk factors or symptoms at all.

Ontario coverage & CONO orderability

OHIP status
insured_conditional
ALT (L223, as 'SGPT (ALT)'), GGT (L107), ALP (L191), bilirubin (L030), and albumin (L005) are each listed by name in the 2026 Schedule of Benefits for Laboratory Services and are insured when ordered by a physician, midwife, or NP who has clinically assessed the patient. AST (L222) carries a specific restriction: it 'is only insured for persons when ordered by or on the advice of a physician with expertise in hepatic disorders' [2]; a routine AST ordered by a family physician with no hepatology involvement is not an insured service and must be marked 'uninsured,' with the patient responsible for payment. ND-ordered testing of any of these is not insured and is billed privately regardless (Reg. 552 s.22(1); SOB-LS 2026 preamble).
CONO orderable
Yes — CONO list #4, #26, #68, #98, #28, #5
CONO list item 4, blood: 'Alanine Transaminase (ALT, SGPT)'; item 26, blood: 'Aspartate Transaminase'; item 68, blood: 'Gamma-glutamyl Transferase (GGT) / GG transpeptidase (GGTP)'; item 98, blood: 'Phosphatase, alkaline'; item 28, blood: 'Bilirubin (total, total conjugated, unconjugated, direct and indirect)'; item 5, blood: 'Albumin, qualitative.'

Linked conditions

Counselling script

“If you have a risk factor like obesity, diabetes, or a liver-related symptom, checking ALT is reasonable, and I'll order that today, along with a repeat or fibrosis score if needed. AST specifically is only an insured test when a physician with hepatology expertise is involved, so I don't order it routinely myself. Without a metabolic risk factor or symptom pointing to your liver, I wouldn't add a full liver panel as routine yearly screening, since an isolated abnormal result in a low-risk person usually just leads to more testing.”

Revisit if

  • New symptoms suggestive of liver disease (jaundice, right upper quadrant pain, dark urine)
  • New metabolic risk factors (obesity, type 2 diabetes, dyslipidemia)
  • Starting a medication known to affect the liver

References

  1. [1]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkSGPT (ALT) (L223) is listed by name in the 2026 OHIP Schedule of Benefits for Laboratory Services
  2. [2]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkAST (L222) is only insured for persons ordered by, or on the advice of, a physician with hepatic expertise
  3. [3]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkGGT (L107) is listed by name in the 2026 OHIP Schedule
  4. [4]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkAlkaline phosphatase (L191) is listed by name in the 2026 OHIP Schedule
  5. [5]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkBilirubin, total (L030) is listed by name in the 2026 OHIP Schedule
  6. [6]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkAlbumin, quantitative (L005) is listed by name in the 2026 OHIP Schedule
  7. [7]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkCommunity lab tests are insured only when ordered under the Schedule by an authorized prescriber
  8. [8]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
  9. [9]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services
  10. [10]American College of Gastroenterology (2017). ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. linkALT, AST, alkaline phosphatase, and bilirubin are the most common liver chemistries ordered; an elevated ALT is associated with increased liver-related mortality
  11. [11]Ajmera et al., Hepatology (validation cohort describing the AGA/AASLD NAFLD clinical pathway) (2024). Validation of AGA clinical care pathway and AASLD practice guidance for nonalcoholic fatty liver disease in a prospective cohort of patients with type 2 diabetes. linkAGA and AASLD have developed clinical pathways using FIB-4 to evaluate populations at high risk for NAFLD, such as patients with type 2 diabetes
  12. [12]College of Family Physicians of Canada / Choosing Wisely Canada (2026). Family Medicine: Fifteen Tests and Treatments to Question. linkDon't do annual screening blood tests unless directly indicated by the patient's risk profile
Evidence notes

The primary AASLD 2023 practice guidance document for NAFLD/MASLD could not itself be fetched and quote-verified in this session (it did not return usable abstract text via the searches performed); the [11] source used instead is a 2024 validation cohort study whose background sentence describes the existence and purpose of the AGA/AASLD risk-based pathway, which is a reasonable secondary citation for that pathway's existence but is not the primary guidance itself, flagged here for reviewer awareness. The physiological point that mild, isolated liver enzyme elevations are often transient (for example related to alcohol, recent exercise, or medications) is standard clinical knowledge that this session did not independently source and is therefore not stated as fact in why_not. Reviewer, flagged for Dr. Yu: the risk-based MASLD pathway uses FIB-4, which needs AST (with ALT, platelets and age). Under the 2026 Schedule, AST (L222) is insured only when ordered by or on the advice of a physician with hepatic expertise. So a family physician calculating FIB-4 may need to mark AST 'uninsured'. How AHC wants to handle this (patient-paid AST, or hepatology advice) is a practice decision, not an evidence question. Resolved 2026-09-23: Dr. Yu chose to state the OHIP rule and leave the choice to the physician, with no AHC policy (decision 9).