GI Bleeding: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient requested reimbursement for inpatient hospital services.Based on the documentation provided for review, the clinical circumstances support the admission to inpatient status for the management of this patient. The timely and accurate diagnosis of gastrointestinal bleeding (GIB) in children is necessary to reduce morbidity and mortality. The patient had two prior significant episodes of GIB, requiring intensive care unit admission with intravenous fluid resuscitation, blood transfusions, intravenous (IV) proton pump inhibitor (PPI), and octreotide. The record indicates that the patient had recently documented anastomotic ulceration during his scope procedure only a few days prior to his admission to the hospital. The patient had received two packed red blood cell transfusions but continued to be symptomatic.

A 59-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of gastrointestinal bleeding. Findings: Three physician reviewers found that the patient has required blood transfusions because of recurrent gastrointestinal hemorrhage. Colonoscopy and upper gastrointestinal endoscopy have been non-diagnostic. A bleeding jejunal arteriovenous malformation was identified during upper endoscopy and was ablated. No other candidate bleeding lesion has been found. The gastrointestinal hemorrhage has been sufficiently severe to result in cardiac complications for which she may require systemic anticoagulation with warfarin.

Where the denial was upheld

Nature of Statutory Criteria/Case SummaryThe patient has requested authorization and coverage for a Cologuard cancer screening test. Findings: The physician reviewer found that evidence on healthcare outcomes of Cologuard versus standard medical care is lacking at this time. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect some adenomas if they have high-grade dysplasia . However, the limited evidence for Cologuard suggests that 154 patients would have to be screened to find one cancer using colonoscopy, versus 166 patients using Cologuard . In addition, there is a lack of consensus in clinical guidelines form the United States Preventive Services Task Force and the American Cancer Society to support that Cologuard has a positive impact on health outcomes as guidelines.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ensure Complete Liquid. Findings: The submitted documentation fails to demonstrate the medical necessity of the requested supplement. The records do not document malabsorption, metabolic syndrome or enteral nutrition given via a feeding tube. The documentation does not support that the patient experienced significant recent weight loss. The treatment of weight loss should be aimed at the underlying illness or medical condition, as well as dietary modification. Nutritional supplements are recommended when patients experience weight loss and dietary modification has not been effective to help them gain weight. This patient has a diagnosis of chronic fatigue syndrome. Various therapies have been tried in patients with chronic fatigue syndrome.

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