Dysphagia: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for whole genome sequencing trio analysis and interpretation. This patient’s diagnosis has not been established and he has multiple complex medical diagnoses such as central sleep apnea, sleep related hypoxemia, dysphagia, and gastroesophageal reflux disease (GERD). In this clinical setting, finding a cause of this patient’s complex phenotype would allow these problems to be appropriately treated. The patient’s PHOX2B testing was unrevealing. The patient’s presentation is severe and unexplained by any known disorder. The patient’s condition may be caused by a genetic syndrome and whole exome sequencing is the best study to uncover the cause, which may potentially prevent life-threatening complications.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with gastroesophageal reflux disease (GERD)/dysphagia. The patient’s body mass index (BMI) was 25 kg/m². The patient underwent a colonoscopy with propofol as anesthesia. His airway was graded with a Mallampati score of one. The patient’s American Society of Anesthesiologists (ASA) score was one, and there was no documentation of a potentially difficult airway. There is no documentation the patient had previous difficulties or problems with anesthesia. There is no record of any cardiac, pulmonary, renal or hepatic comorbidities. The patient was not on any outpatient medications and did not have any known drug allergies. There is no documentation that the patient had issues with substance abuse or was a smoker. The patient has requested reimbursement for anesthesia CPT-00812 (34 units) for his colonoscopy.

Nature of Statutory Criteria/ Case Summary: Findings the physician reviewer found that coverage for speech therapy, three times per week at 30 minutes per session. The enrollee has a history of hypoplastic aorta syndrome, hypoplastic left heart syndrome, ventricular septal defect, and two strokes. After the second stroke, he has diagnoses of chorea, apraxia, developmental delay, and speech delay. He has been receiving speech therapy services for mixed receptive-expressive language, dysphagia, and phonological disorder. At school, he receives speech and language services two times per week as part of his special education program. He continued to receive outpatient speech therapy to increase lingual and labial strength, rate, coordination, and range of motion; increase fluency and intelligibility; improve grammar and syntax, and; improve comprehension of compound negative sentences.

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 dysphagia was denied, the published record says the denial is worth fighting.