Celiac Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

An 18-year-old female enrollee has requested an upper gastrointestinal (GI) endoscopy, or esophagogastroduodenoscopy (EGD) for evaluation of her epigastric abdominal pain. Findings: The physician reviewer found that this patient’s records suggest that there is a low to moderate suspicion for celiac disease. In general, the first step in management includes assessing for celiac antibodies such as IgA tissue transglutamase antibodies. To that end, an EGD would not be indicated as a first diagnostic step. However, in this patient with upper GI tract symptoms and occult blood in the stool, performing an EGD is clinically indicated and supported in the medical literature.

The parent of a five-year-old male enrollee has requested reimbursement for laboratory testing,codes 83890, 83896, 83898 and 83912, for evaluation of the enrollee’s abdominal pain. Findings: Two physician reviewers found that Celiac disease is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. This can result in typical malabsorption syndrome (chronic diarrhea, weight loss and abdominal distention) and a spectrum of symptoms potentially affecting any organ or body system, including chronic abdominal pain and constipation. Fasano and Catassi (2005) recommended the use of serological genetic celiac disease tests in order to identify these cases in a timely fashion to prevent serious complications secondary to untreated celiac disease.

Where the denial was upheld

Physician 1: This patient is a 14-year-old female whose parents are requesting authorization and coverage for celiac gene testing. The patient has thyroiditis and Type 1 diabetes; during workup of these conditions screening markers suggested the patient might have celiac disease. The patient’s provider indicates that since the patient is currently on a non-wheat diet, standard testing for celiac disease is not possible; instead, genetic testing for the presence of HLADQ2 and HLADQ8 has been requested. The Health Plan has denied coverage for celiac gene testing on the basis it is considered investigational.Review of the relevant medical literature reveals celiac gene testing remains investigational. Since the patient is on a non-wheat diet, the development of celiac disease will not occur; thus, genetic testing is not justifiable.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a diagnostic test with a wireless capsule endoscopy for evaluation of her Celiac disease (CD). Findings: Two physician reviewers found that according to the American College of Gastroenterology guidelines, a capsule endoscopy should not be used for an initial diagnosis except for patients with positive celiac sprue serology who are unwilling to undergo upper endoscopy and biopsy. The diagnosis is confirmed by duodenal mucosal biopsies. The sensitivity of capsule endoscopy is less when there is partial villous atrophy and all non-atrophic lesions (Marsh I–II) may elude visual detection. The capsule endoscopy should be reserved for the patients with complicated CD, such as patients with refractory CD and persistent diarrhea, abdominal pain, weight loss and hypoalbuminemia.

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 celiac disease, then check the rights and deadlines that apply to your plan.