Inflammatory Bowel denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for a gastrointestinal tract capsule endoscopy of the small bowel. The records document that this patient has had symptoms and elevated calprotectin with normal colonoscopy, suggestive of possible small intestinal Crohn’s disease rather than the current diagnosis of ulcerative colitis. Capsule endoscopy is useful for the diagnosis of Crohn’s Disease or determination of the extent of disease activity, and superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has been demonstrated to be superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohn’s disease. Therefore, the test is supported by guidelines for the diagnosis of Crohn’s disease.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rifaximin (Xifaxan). Findings: The physician reviewer found that the use of Xifaxan is supported by current medical literature for both pouchitis and prophylaxis of hepatic encephalopathy. A meta-analysis of nine studies, including three randomized controlled trials, has demonstrated that antibiotic use is associated with a significant improvement in pouchitis compared to placebo or other treatment. Antibiotic-dependent pouchitis often requires chronic antibiotic therapy. In a study of 51 patients with antibiotic-dependent pouchitis, Xifaxan was used as long-term maintenance therapy after proctocolectomy with ileo-anal pouch. One study in 16 patients with antibiotic- and probiotic-refractory pouchitis demonstrated 81% of patients achieved remission with Xifaxan.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fecal calprotectin testing for evaluation of the enrollee’s possible inflammatory bowel disease. Findings: The 3 physician reviewers found that the use of fecal calprotectin testing to diagnose change in bowel habits has not been accepted for routine use in this clinical setting. According to the American College of Physicians (ACP) “a specialist might measure fecal calprotectin, but only in conjunction with detailed history-taking, clinical examination, and serum inflammatory markers or other blood tests, to determine the need for endoscopic evaluation”. The ACP also stated that “fecal calprotectin is elevated in several other gastrointestinal diseases, including viral, bacterial, and protozoal causes of infective diarrhea”.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested breath hydrogen or methane test for evaluation of the enrollee’s dyspepsia. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient’s symptoms and medical work-up are reassuring for the absence of an inflammatory, progressive, or life-threatening condition. The medical records suggest a functional condition akin to irritable bowel syndrome (IBS). While small intestinal bacterial overgrowth (SIBO) may exacerbate symptoms of IBS, lactulose breath testing is not a reliable means of determining whether SIBO is present or whether treatment of SIBO is liable to lead to symptom improvement.

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