Helicobacter Pylori Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Helicobacter pylori (H. pylori) serological antibody test (CPT 86677). Findings: The physician reviewer found that the American College of Gastroenterology (ACG) guidelines for dyspepsia support the use of H. pylori testing for evaluation of specific symptoms, as in this patient’s case. Current medical literature supports the use of H. pylori testing to rule out this infection as a cause for pain in well-selected patients. In this patient with dyspepsia and no documented prior treatment for H. pylori infection, the H. pylori immunoglobulin G (IgG) antibody would be expected to be elevated in the presence of ongoing infection. Use of the H. pylori serological antibody test can help avoid more extensive testing and facilitate treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Pylera for the treatment of H. pylori. Findings: The physician reviewer found that patients who have failed clarithromycin regimens should not be retreated with those due to high risk of resistance and treatment failure. In this case, the patient has failed such a regimen, and another triple therapy regimen. Song and colleague have noted that Pylera has been effective after failure of clarithromycin-containing triple therapy, and in patients who had failure of 3 prior triple therapies including patients resistant to fluoroquinolones and metronidazole. Malfertheiner and colleagues found that the timing of drug administration for Pylera is simpler than use of the generic bismuth quadruple therapy, resulting in a compliance rate above 95%.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a helicobacter pylori infection. The patient reported epigastric pain. The patient had been taking meloxicam for neck pain. The treatment plan included starting pantoprazole and performing Helicobacter pylori testing. The patient underwent stool antigen testing for Helicobacter pylori infection, and the results were positive. The patient has requested reimbursement for Pylera (120 capsule blister pack) received. The Health Plan denied the request and reported the medication at issue was not medically necessary for the treatment of this patient. At issue in this case is whether Pylera (120 capsule blister pack) received was medically necessary for the treatment of the patient’s medical condition. Researchers reported, “Helicobacter pylori (H.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for serological antibody testing for Helicobacter pylori.Findings: Two out of three physician reviewers found that this patient reported a history of Helicobacter pylori infection. Medical literatures noted “Helicobacter pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available.” Consistent with standard of care, the researchers noted “13C urea breath test or the stool antigen test can be used for noninvasive screening for Helicobacter pylori in a ‘test and treat strategy’ in younger patients presenting with dyspepsia without alarm symptoms” and without the need for endoscopic prelude to therapy or re-treatment. The medical evidence does not support serologic testing for the evaluation of this patient.

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 helicobacter pylori infection was denied, the published record says the denial is worth fighting.