Nonalcoholic fatty liver disease is the most common liver disease, affecting close to 83.1 million individuals in the United States. About a third of these patients will develop nonalcoholic steatohepatitis (NASH), which ultimately can lead to cirrhosis, the most critical risk factor for hepatocellular carcinoma (HCC). To cure HCC, its detection must be in the early stages; hence, surveillance is recommended in those individuals with NASH-cirrhosis whose yearly risk is more than 1.5%/year. While observational data shows that 20–30% of HCC develops in patients with NAFLD in the absence of cirrhosis, we provide in this chapter the rationale for why we do not recommend the current tools’ surveillance of HCC in NAFLD patients without cirrhosis. The three major reasons are: first, we do not have a clear understanding of which risk factors are key in the development of HCC in non-cirrhotic NAFLD; second, the surveillance techniques are far from perfect and confounded by the fact that these patients may be low-quality surveillance exams, and finally, surveillance can result in the overdiagnosis of HCC in, otherwise, not eligible for treatment due to other comorbidities commonly present in patients with NAFLD. We conclude that while surveillance is vital in patients with NASH cirrhosis, based on available data, we cannot recommend a mass screening in patients without cirrhosis.