Diarrhea 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 endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test. The records provided for review document the presence of dysphagia and odynophagia. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted as an initial test for evaluation of patients with dysphagia. In patients with dysphagia, there is concern for eosinophilic esophagitis, and endoscopic biopsy is currently the only method for diagnosis. In addition, this patient’s odynophagia could be due to etiologies such as candidiasis, esophagitis, and ulceration, most accurately diagnosed by endoscopy. Therefore, the requested endoscopy with biopsies is medically necessary for the evaluation of this patient’s dysphagia and odynophagia.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for colonoscopy and urgent and immediate scheduling of the colonoscopy. One study evaluated the data on diagnostic yield of colonoscopy in young adult patients with lower gastrointestinal (GI) symptoms. The authors concluded that for patients with lower GI symptoms, the need for endoscopic evaluations should be determined clinically on a case-by-case basis. Another study found that chronic diarrhea and abdominal pain, rectal bleeding, and constipation were major indications for colonoscopy performance in quadragenarian and younger patients. The authors noted that rectal bleeding was associated with colorectal cancer development in young patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for IgG food sensitivity testing for evaluation of the enrollee, who has a history of gastrointestinal symptoms. Findings: Three physician reviewers found that the patient has a history of diarrhea, bloating and weight gain. She was noted to have eliminated wheat from her diet and was doing better with less bloating and diarrhea. The patient had comprehensive metabolic panel, celiac panel, and immunoglobulin G (IgG) test. Her celiac panel was normal and her IgG to wheat was positive. The patient requests reimbursement for the IgG food sensitivity testing. The Health Plan denied reimbursement for the services at issue. The Health Plan deemed the services at issue as investigational for the evaluation of this patient’s medical condition.

Nature of Statutory Criteria/Case Summary: The fecal laboratory testing performed in this case was recommended to evaluate the patient for various pathogens that can cause diarrhea. However, there is a lack of well-designed randomized controlled trials comparing this technology with conventional methods of testing for gastrointestinal infectious pathogens. A provider typically utilizes the clinical history obtained from the patient along with the physical examination, standard laboratory testing, radiographic data, and endoscopic evaluation to make an assessment. Currently, routine panel testing of patients who present with diarrhea is not considered the standard of care. Moreover, many of the pathogens included in the testing had a low pre-test probability of contributing to the patient’s presentation.

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