Irritable Bowel Syndrome denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested authorization and coverage for percutaneous electrical nerve field stimulation (PENFS) with IB Stim device. Researchers report, “There is insufficient evidence to recommend any therapeutic intervention in pediatric irritable bowel syndrome.” Researchers note that the heterogeneity of pediatric irritable bowel syndrome makes it challenging to design a treatment algorithm that fits all children. The authors further note that while multiple interventions are available, certain interventions approved for adults are not recommended for children due to the need for more data before definitive conclusions can be drawn and the concern for the adverse effects of long-term use of many pharmacologic treatments in children.

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for S-Boulardii, Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, L-Arginine low dosage, D-Ribose pure powder 500 mg, and Natural Calm plus calcium supplements for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that The request for Saccharomyces boulardii (S-boulardii) is supported as medically necessary for treatment of this patient’s medical condition. This probiotic has demonstrated efficacy for the treatment of irritable bowel syndrome, which this patient has (Kelesidis and Pothoulakis,). However, the remaining requested items are not supported as medically necessary.

Where the denial was upheld

Physician 1: The patient is a 58-year-old woman with a reported history of chronic diarrhea and “spastic colitis” for 20 years. There is no documented history of abdominal pain, weight loss or loss of appetite. The patient has a past medical history of cervical cancer, asthma, peptic ulcer and gallbladder sludge. She has had a flexible sigmoidoscopy and barium enema in the past. The patient was given the option of conventional colonoscopy versus CT colonography (also known as virtual colonoscopy) and elected to undergo the latter. The results of the virtual colonoscopy were normal.

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for enteral formula (Ensure nutritional drinks). The Health Plan has denied this request indicating that the requested nutritional drink is not medically necessary for treatment of the enrollee’s irritable bowel syndrome. A review of the record indicates that the enrollee has been diagnosed with somatoform disorder; gastritis; fibromyalgia; anxiety; weight loss; post-traumatic stress disorder; anorexia; gastroduodenitis without bleeding; and irritable bowel syndrome without diarrhea. A visit note, reported the enrollee presented with weight loss and abdominal pain. The enrollee reported a visit in the emergency room, for abdominal pain and nausea. The enrollee reported severe constipation and daily laxative use and takes a laxative every time she eats solid food.

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