Gastroparesis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 45-year-old woman who has had diabetes since the age of 10 with long standing symptoms of nausea and vomiting from gastroparesis, particularly at night. She also has hypertension. Currently, she is maintained on an insulin pump. She has failed to have improvement with conventional therapy and has used domperidone without improvement. The patient underwent endoscopy (which did not demonstrate an anatomic cause for symptoms) with injection of Botox into the pylorus (which did resolve her symptoms). She has had an abnormal, delayed gastric emptying study on two occasions and an electrogastrogram performed in February 2004 was abnormal. A trial of Enterra therapy has been recommended.

Nature of Statutory Criteria/Case Summary: An enrollee has requested gastric emptying study, a computed tomography (CT) angiography and a fecal microbiota transplant for treatment of the enrollee, who has a history of abdominal pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. This patient has symptoms consistent with gastroparesis, but also consistent with other diseases.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute hospitalization level of care, subacute hospitalization level of care, a chest computed tomography (CT) with contrast, and abdominal CT with contrast. The records provided for review document that this patient has undergone an extensive work-up and evaluation with multiple specialists for her ongoing symptoms of intermittent, small-volume emesis, and atypical chest pain. The patient has been hemodynamically stable with intermittent vomiting. The patient does not have any medical conditions that require acute or subacute hospital level of care services. Accordingly, the requested acute hospitalization level of care, or subacute hospitalization level of care, is not medically necessary for treatment of this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wireless capsule endoscopy (SmartPill Monitoring System) CPT code 91112 for evaluation of the enrollee’s gastroparesis. Findings: The physician reviewer found that The SmartPill wireless capsule endoscopy is U.S. Food and Drug Administration (FDA) approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. The device is recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, wireless capsule endoscopy has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and has not been demonstrated to be superior to gastric motility or colon transit testing.

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