Chronic Diarrhea denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with irritable bowel syndrome with diarrhea (IBS-D). The patient reported diarrhea, nausea, and unintentional weight loss. The patient underwent a colonoscopy that revealed non-bleeding internal hemorrhoids. The random colon biopsies obtained were noted to be negative for adenomatous change or malignancy. The patient reported diarrhea and abdominal cramping, which improved after bowel movements. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request Form, the provider noted loperamide was ineffective. A computed tomography scan of the abdomen and pelvis showed a distended gallbladder, diverticulosis, and a stable right lung nodule. An ultrasound of the abdomen, showed multiple gallstones in a nondilated gallbladder.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation of Entyvio 300 mg IV infusion to every four weeks. The request to continue Entyvio 300 mg every four weeks is supported as medically necessary for the treatment of this patient’s Crohn’s disease. In two randomized placebo-controlled trials, which supported U.S. Food and Drug Administration (FDA) approval, Entyvio was part of a study protocol for patients who had not achieved remission despite six weeks of treatment and continued Entyvio every four weeks rather than every eight weeks. The American Gastroenterological Association (AGA) indicated that for patients with Crohn’s disease, Entyvio every four weeks resulted in remission in over 36% of patients after one year.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during upper and lower gastrointestinal endoscopic procedures. The current American Society of Anesthesiologists (ASA) guidelines for sedation and anesthesia in gastrointestinal endoscopy “recommend that the combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events.” The ASA states that, “Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III.” A review by Wernli and colleagues concluded that, “Use of anesthesia service was associated with a 13% increase in the risk of any complication within 30 days.” In this case, the patient p…

A 66-year-old male enrollee has requested anesthesia administered during a colonoscopy for treatment of his history of chronic diarrhea. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patient’s case. The American Association of Anesthesiologists notes that moderate sedation is generally recommended for both diagnostic and uncomplicated therapeutic endoscopic procedures. Moderate sedation involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the patient’s ability to respond to stimulation.

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 chronic diarrhea, then check the rights and deadlines that apply to your plan.