Small Intestinal Bacterial Overgrowth denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic fatigue disorder and fibromyalgia. The patient reported bloating, burping and flatulence. He was noted to have had irritable bowel syndrome (IBS) since he was a teenager. His symptoms initially responded to erythromycin and worsened with dicyclomine. The provider reported concern for small intestinal bacterial overgrowth (SIBO), although testing was not possible due to COVID-19. The provider noted Xifaxan is indicated for the treatment of SIBO. The patient was noted to be allergic to penicillin. The provider noted a delay in treatment is causing the patient stress in the setting of his post-traumatic stress disorder, bipolar disorder, borderline personality disorder, and anxiety. The patient reported the return of abdominal pain after treatment with neomycin.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting reimbursement for four continuous weeks of Xifaxan. The enrollee has irritable bowel syndrome. He completed a lactulose breath test, which tested positive for hydrogen, resulting in a diagnosis of small intestinal bacterial overgrowth (SIBO). Xifaxan was prescribed for four weeks on the basis that hydrogen is best treated with this medication. The physician notes metronidazole is effective only in treating methane. Cipro and tetracycline have not proven to be effective in treating hydrogen. The patient indicates his condition has improved since starting Xifaxan and continues to improve over time. Literature supports the treatment of small intestinal bacterial overgrowth (SIBO) for patients with irritable bowel syndrome with diarrhea (IBS-D) who are positive for hydrogen on the lactulose breath test.

Where the denial was upheld

Physician 1: This patient is a 54-year-old female who has irritable bowel syndrome, constipation predominant subtype (IBS-C) and apparently was tested for small bowel bacteria with positive results. Her treating physician is now recommending treatment with a recently described antimicrobial regimen of Xifaxan and neomycin in an effort to resolve her bacterial overgrowth and symptoms of IBS-C. The Health Plan has denied coverage for Xifaxan on the basis it is considered investigational for treatment of the patient’s medical condition.The issue of the prevalence and putative association of small intestinal bacterial overgrowth with IBS and functional dyspepsia have been and remain controversial.

Nature of Statutory Criteria/Case Summary: The parents of the patient requested Xifaxan 550 mg tablets.Xifaxan may be considered in the treatment of pediatric patients with a diagnosis of small intestinal bacterial overgrowth (SIBO). The use of Xifaxan in treating small intestinal bacterial overgrowth (SIBO) is appropriate and supported by adequate peer-reviewed literature. However, there is no evidence that Xifaxan is superior to the available medications. A study found that Xifaxan treatment seems to be effective and safe for the treatment of SIBO. However, the authors indicated that well-designed randomized controlled trials are needed to substantiate these findings and to establish the optimal regimen.

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 small intestinal bacterial overgrowth, then check the rights and deadlines that apply to your plan.