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Hepatocellular carcinoma (HCC) is one of the neoplasms with a growing incidence. Only a limited number of studies evaluated the diagnostic performance of CEUS LI-RADS. Clinical utility of ancillary features (AFs) in CEUS LI-RADS is yet to be established. We assessed the diagnostic yield of CEUS LI-RADS and AFs in HCC. To our knowledge, this is the first blind study of CEUS application in assessing focal liver lesions (FLL) by using the LI-RADS algorithm and AFs. We retrospectively included patients with risk factors for HCC with newly diagnosed FLL, hospitalized between January 2016 and December 2019 in the Gastroenterology Department of Emergency County Hospital of Craiova, Romania. All lesions have been categorized according to the CEUS LI-RADS v2017 by an experienced sonographer blinded to clinical data and to the final diagnosis. CEUS AFs in favor of benignity were size reduction or stability >2 years of the tumor. The malignancy aspects were: definite growth, nodule in nodule architecture and mosaic architecture, favoring HCC in particular. Diagnostic accuracy of CEUS was calculated. From a total of 143 patients with 191 FLL, AFs favoring HCC were observed in 19.8% cases as hypoechoic rim and in 16.7% cases as nodule in nodule architecture. From the total of 141 HCC cases, 118 of them (83.6%) were correctly classified as HCC diagnosis, as follows: 81 tumors (57.4%)—definitely HCC (LR-5) and 37 tumors (26.2%)—probably HCC (LR-4). In 13 cases (9.21%), CEUS characteristics indicated malignant lesions, but not necessarily HCC (LR-M); 3 cases (2.12%) were classified as intermediate probability of malignancy (LR-3); none of them was incorrectly diagnosed as benign. The LR-5 category was 96.2% (95% CI: 89.4–98.7%) predictive (PPV) of HCC, with one case of misdiagnosis for cholangiocarcinoma. CEUS LR-5 sensitivity for HCC was 60.4% and specificity was 93.6%. Regarding the LR-4 category, PPV was 94.8%, with only 26.2% sensitivity, whereas for LR-3 the PPV was 41.02%, with only 2% sensitivity. CEUS LIRADS algorithm including AFs remains an excellent diagnostic tool for HCC. [ABSTRACT FROM AUTHOR]