Gastroesophageal Reflux Disease: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: This patient is a 40-year-old male who has had reflux symptoms for the past five years. An endoscopy showed normal esophagus, no evidence of hiatal hernia and antral gastritis. A Bravo capsule for pH measurement was mildly abnormal the first day and normal the second day. The patient has tried PPIs, which have stopped working for him and cause side effects. His esophageal manometry was also unremarkable.The patient’s provider has recommended the patient undergo a Stretta procedure. The Health Plan has denied authorization for the requested procedure on the basis it is considered investigational.Review of the relevant scientific literature reveals growing support for the Stretta procedure. There have been an increasing number of studies demonstrating the safety and efficacy of this procedure.

Physician 1: The patient is a 46-year-old female with idiopathic gastroparesis, gastroesophageal reflux disease, chronic abdominal pain and constipation. She had an extensive gastrointestinal work up which identified negative lower esophageal sphincter tone and severe gastroparesis. The patient has daily symptoms of reflux and regurgitation and has had multiple hospitalizations for recurrent abdominal pain, nausea, vomiting and dehydration. She was treated with Propulsid when the drug was available and Reglan until she developed an allergy to the drug. The patient failed treatment with erythromycin but was started on Zelnorm with some improvement in her symptoms of abdominal pain and constipation. She has still required hospitalization for recurrent abdominal pain, nausea and vomiting, failure to thrive, line sepsis and deep vein thrombosis.

Where the denial was upheld

Physician 1The patient is a 53-year-old female with numerous upper gastrointestinal complaints with no evidence of complicated GERD (e.g., esophagitis, stricture, Barrett’s syndrome). There is mild reflux physiology without evidence of a hiatal hernia, and an ambulatory pH study showing upright reflux only, not supine. There are possibly other aggravating factors, such as gastroparesis, making symptom response difficult to judge. Additionally, the patient has functional elements including non-obstructive dysphagia and medication intolerance. The patient has requested authorization to undergo the Stretta procedure.

Physician 1The patient is a 45-year-old female patient with reflux symptoms who has been on multiple proton pump inhibitors (PPIs) and H2 blockers. An EGD performed in October 2002 revealed reflux esophagitis. The patient’s provider has recommended an Enteryx procedure. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental.The efficacy of the Enteryx procedure has not been established. The largest study to date, a multicenter trial of 81 patients, shows 73% of patients who were followed for more than two years had significant improvement in their PPI dependency (Johnson DA, et al.). A recent article in Gastroenterology and Endoscopy News, revealed there is an ongoing open label investigation of the Enteryx procedure with 45-month follow-up data collected from 42 patients.

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 gastroesophageal reflux disease was denied, the published record says the denial is worth fighting.