Pancreatitis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Applying Sections 1317.1(a) and 1317.1(b), a portion of the laboratory testing including lipase, comprehensive metabolic panel, and lipid panel, and the physical examination were provided for the treatment of an emergency medical condition. The patient initially reported symptoms concerning for acute pancreatitis, and elevated triglycerides were found, which can cause acute pancreatitis. A diagnosis of acute pancreatitis requires two of three findings, including symptoms consistent with pancreatitis, elevated lipase greater than three times the upper limit of normal, and/or imaging consistent with pancreatitis (Banks, et al.; Garber, et al.). In order to determine whether acute pancreatitis was present, the patient’s lipase had to be tested.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoscopy with biopsies, colonoscopy with biopsies, and esophageal manometry test. The records provided for review document the presence of dysphagia and odynophagia. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted as an initial test for evaluation of patients with dysphagia. In patients with dysphagia, there is concern for eosinophilic esophagitis, and endoscopic biopsy is currently the only method for diagnosis. In addition, this patient’s odynophagia could be due to etiologies such as candidiasis, esophagitis, and ulceration, most accurately diagnosed by endoscopy. Therefore, the requested endoscopy with biopsies is medically necessary for the evaluation of this patient’s dysphagia and odynophagia.

Where the denial was upheld

A 60-year-old female enrollee has requested office visits, physical medicine rehab and injection of tendon and coverage for future services for treatment of her pancreatitis and lumbar spondylolisthesis. Findings: Three physician reviewers found that the medical records provided are brief and are accompanied by a typed document of an unknown source entitled Auriculoneural Therapy which describes this therapy as a technique involving the detection of tender spots or points with reduced electrical resistance on the ear which coincides with painful and/or symptomatic areas of the body. In review of this case, there is a lack of detailed medical records from the attending physician demonstrating the necessity of the services at issue.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Fentora for treatment of her medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medical necessity for Fentora has not been established. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, long-term opiates are more likely to cause adverse outcomes.

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