Abdominal Stomach Pain: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic fatigue disorder and fibromyalgia. The patient reported bloating, burping and flatulence. He was noted to have had irritable bowel syndrome (IBS) since he was a teenager. His symptoms initially responded to erythromycin and worsened with dicyclomine. The provider reported concern for small intestinal bacterial overgrowth (SIBO), although testing was not possible due to COVID-19. The provider noted Xifaxan is indicated for the treatment of SIBO. The patient was noted to be allergic to penicillin. The provider noted a delay in treatment is causing the patient stress in the setting of his post-traumatic stress disorder, bipolar disorder, borderline personality disorder, and anxiety. The patient reported the return of abdominal pain after treatment with neomycin.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty, or flap elevation. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for esophagogastroduodenoscopy (EGD) with anesthesia for the upper gastrointestinal endoscopic procedure. The Clinical Guidelines Committee of the American College of Physicians recommend endoscopy for investigation of upper gastrointestinal symptoms, such as dyspepsia or gastroesophageal reflux disease (GERD), when those symptoms are refractory to proton pump inhibitor (PPI) therapy taken properly for four to eight weeks without response. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is generally indicated if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for abdominal stomach pain was denied, the published record says the denial is worth fighting.