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

Where the denial was overturned

The patient has requested authorization and coverage for endoscopy and monitored anesthesia care during the endoscopy procedure. Based on the available documentation, the requested endoscopy is medically necessary for evaluation of this patient. The patient has had rectal bleeding. Per the most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines, endoscopy is supported when there is active or recent gastrointestinal bleeding. Endoscopy is appropriate to evaluate the patient for bleeding sources such as a duodenal ulcer. Given this support, the requested endoscopy is medically necessary for evaluation of this patient. However, the records do not support the medical necessity of monitored anesthesia care during the endoscopy procedure.

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a consultation with a gastroenterologist specialist.The most recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) recommend procedural evaluation of bleeding, which is not documented in this case, and Gastroenterology consultation is warranted to determine if this is appropriate (ASGE Standards of Practice Committee, et al.). Additionally, Mott and colleagues recommend evaluation for alternative causes of symptoms, including fissure and inflammatory bowel disease. Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Gastroenterology (ACG) recommend workup for other causes of symptoms and various procedural interventions for hemorrhoids which do not respond to conservative medical therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anesthesia during endoscopy.Findings: The physician reviewer found that American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee noted that the “combination of an opioid and benzodiazepine is a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in patients without risk factors for sedation-related adverse events.” The authors recommended that, “anesthesia provider–administered sedation be considered for complex endoscopic procedures or patients with multiple medical comorbidities or at risk for airway compromise.” The guidelines also noted, “Minimal and/or moderate sedation can be delivered safely by endoscopists to patients who are American Society of Anesthesiologists (ASA) Class I, II, or III.

Nature of Statutory Criteria/Case Summary: The patient is a 52-year-old female. Per the provider, the patient had severe diarrhea requiring Pedialyte. The patient has a family history of colon cancer based on a prior colonoscopy performed in 2017. Per the gastroenterology report, the patient’s brother had colon cancer and her mother had gastric cancer. A colonoscopy (complete up to the cecum with adequate preparation) report showed left colon diverticulosis and scarring in the rectum. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for evaluation of this patient. At issue in this case is whether a colonoscopy for a biopsy is medically necessary for the evaluation of the patient’s medical condition.

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