Abdominal Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast. In this case, the patient has abdominal pain, and an etiology has not been determined using ultrasound of the abdomen. The American College of Radiology (ACR) notes that CT scan is beneficial in diagnosing adult patients with abdominal pain and is considered the first-line imaging modality for this indication in this population. CT scans are broadly used in clinical practice for the evaluation of abdominal pain as there are several medical diseases with nonspecific symptoms which cannot be diagnosed with a physical examination alone. For example, CT is the most sensitive diagnostic method for adult intussusception, which presents with non-specific abdominal pain.

The enrollee requested wireless capsule endoscopy. She has a history of abdominal pain. She experienced constant pain between her shoulder blades and frequent eructation and epigastric discomfort to the left upper quadrant, which did not respond to proton pump inhibitors or over-the-counter simethicone. An upper endoscopy was normal. A computed tomography scan noted a seven millimeter structure the distal ileum, which may represent bowel or a polyp. The gastroenterologist recommended a colonoscopy to evaluate the area in the distal ileum, with a follow-up capsule endoscopy. The wireless capsule endoscopy noted no evidence of a small bowel lesion or polyp, but detected a small foreign body in the distal small bowel. The gastroenterologist indicates the procedure was necessary due to the lesion on the distal ileum noted on the computed tomography scan.

Where the denial was upheld

A 41-year-old female enrollee has requested CPT codes, 99215, 36415, 76977, 82270 X 3, 82365, 82397 x 122, 99000, 99001, 93720, 93922 x 2, 94010 x 2, A4649 x 4, A4556NU, A4617NU X 2, A4927NU, 99214, and 82365, for evaluation of her medical condition. Findings: The physician reviewer found that with regard to CPT code 76977 (bone mass screening by ultrasound), this study was not medically necessary in a patient of this patient’s age without a history of hyperparathyroidism. In addition, there were no clinical indications for CPT code 82365 (infrared spectroscopy) based on the documentation provided. CPT code 82397 (chemoluminescence), is not within the standard of care in this particular setting and thus was not medically necessary. CPT code 93720 (body plethysmography) is indicated for patients who have air spaces within the lung that do not communicate with the bronchial tree.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has reimbursement for computed tomography (CT) scan. The submitted documentation does not support the medical necessity of the patient’s CT scan in a hospital outpatient setting. According to researchers a CT scan is beneficial in diagnosing patients with abdominal pain and is considered the first-line imaging modality for this indication. There are several diseases with nonspecific symptoms that cannot be diagnosed with a physical examination alone. In such cases, CT is the most sensitive diagnostic method for diagnosis. CT has also become a primary imaging test for the evaluation of the small bowel and is especially beneficial in the diagnosis of Crohn’s disease and ulcerative colitis, which are possible explanations for the patient’s symptoms in this case.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving abdominal pain, then check the rights and deadlines that apply to your plan.