Hepatocellular carcinoma (HCC) has a dismal prognosis if not diagnosed early enough to benefit from potentially curative treatments. Although high-quality data supporting HCC surveillance are limited, all expert societies recommend surveillance in some populations. Biannual ultrasound surveillance, with or without alpha-fetoprotein, is recommended in at-risk patients, including those with HCV-related cirrhosis. However, there is no consensus on whether those with HCV-related F3 fibrosis are among the “at-risk group”, particularly after the achievement of sustained virological response (SVR). The cost-effectiveness of HCC surveillance is very sensitive to HCC incidence. Surveillance is generally considered cost-effective with HCC incidence above 1.5%/year before and 1.3%/year after SVR; however, with higher willingness-to-pay thresholds, surveillance may be cost-effective in any population with an incidence of ≥1%/year. Multiple studies have confirmed that HCC risk is markedly reduced, but not eliminated post-SVR. For those with clear evidence of pre-treatment cirrhosis, long-term follow-up data confirm that the risk remains above 1%/year. However, for those with advanced fibrosis but without clear cirrhosis (i.e., F3), the data are less clear. Although the risk with F3 is clearly lower than with F4, distinguishing F3 from F4 may be challenging. Long-term studies suggest that pre-treatment non-invasive measures of fibrosis, particularly FIB-4, may allow for accurate risk stratification. Without clear evidence of cirrhosis and pre-treatment FIB-4 < 3.25, HCC incidence is low post-SVR and surveillance is unlikely to be cost-effective, whereas with obvious cirrhosis and/or FIB-4 ≥ 3.25, HCC incidence remains above the thresholds for which surveillance is likely cost-effective. Until better and more individualized tools are available, pre-treatment FIB-4 and evaluation for clinical evidence of cirrhosis may be the most useful tools to determine who requires HCC surveillance after a viral cure.