Constipation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral to a gastroenterologist for evaluation of the enrollee’s constipation. The physician reviewer found that the submitted documentation establishes the medical necessity of the requested referral. According to the documentation submitted for review, the patient presents with gastrointestinal (GI) symptoms that warrant further evaluation. “Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for electrostimulation biofeedback physiotherapy (a total of six one-hour sessions). Electrostimulation biofeedback physiotherapy is a pelvic floor rehabilitation technique that is well supported in current medical literature for the treatment of urinary/fecal incontinence, pelvic pain, erectile dysfunction, defecatory disorders, and dyssynergic defecation. These techniques are largely designed to increase the internal urethral and rectal sphincter tone to avoid incontinence. Researchers report that biofeedback is an effective therapy for defecatory disorders and for constipation with dyssynergic defecation.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report). Findings: The physician reviewer found that his patient presented with complaints of constipation, fecal incontinence, urgency, and a history of Parkinson’s disease. The current peer-reviewed medical literature does not recommend use of the Smartpill for evaluation of symptoms such as constipation, fecal incontinence, and urgency. The Agency for Healthcare Research and Quality (AHRQ) conducted a systematic review on the effectiveness of the Smartpill compared with other available tests for the evaluation of gastric and colonic motility.

Nature of Statutory Criteria/Case Summary: An enrollee has requested ambulance transport services on an emergent or urgent basis. Findings: The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought ambulance transport on the date in question. In this case, emergency medical services were dispatched due to intermittent abdominal pain. His vital signs were normal. He was in mild distress. He was able to ambulate with assistance to the ambulance stretcher. There is no documentation that the patient suffered from a condition that risked placing the patient’s health in serious jeopardy, causing serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. All told, the services did not meet prudent layperson criteria for emergency care.

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