Gastritis: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient has requested authorization and coverage for acute hospitalization until a definitive diagnosis is determined; subacute hospitalization thereafter for the duration of recovery; one-on-one sitter to monitor risk of aspiration with oral suctioning; physical therapy; occupational therapy; speech therapy; a gastroenterology consultation/second opinion; neurology consultation/second opinion; an otolaryngology consultation/second opinion; a neuro-oncology consultation/second opinion; and/or a cardiology consultation. Based on the available documentation, this patient’s vomiting could be multifactorial due to her chronic medical conditions. The cause for her intractable vomiting has not been determined. The patient has been treated for gastroparesis with placement of a J-tube, consistent with the recommendations from the American College of Gastroenterology (ACG).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings: The physician reviewer found that the patient presented to the emergency department with reports of abdominal pain located in the lower abdomen that began suddenly two days prior and had become persistent. Her symptoms commenced after eating pizza. She reported nausea, vomiting and low back pain. The patient’s past medical history included diabetes and hypercholesterolemia. Her vital signs showed a blood pressure of 122/69, temperature of 98.3 F and pulse of 72. Mild abdominal tenderness was present in all four quadrants with a positive Murphy’s sign. Laboratory data revealed ketonuria with a glucose of 144, but was unremarkable. An abdominal ultrasound was negative for gallstones or cholecystitis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for monitored anesthesia care (MAC) services provided during an endoscope procedure. The current guidelines for sedation and anesthesia in gastrointestinal endoscopy concluded that that use of a “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 guidelines further state that, “Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are ASA Class I, II, or III.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. On review of the available documentation, this patient presents with a history of abdominal pain, gastritis, and small sliding hiatal hernia. The patient’s provider has recommended valuation with wireless capsule endoscopy. As noted in the medical literature, wireless capsule endoscopy is recommended for the evaluation of patients for possible causes of small bowel bleeding, suspected Crohn’s disease, or abnormal small bowel imaging. One study noted that possible indications for small bowel capsule endoscopy include “obscure gastrointestinal bleeding, Crohn’s disease, small-intestinal polyps and tumors, and celiac disease”.

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