Capsule Endoscopy 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: An enrollee has requested capsule endoscopy for evaluation of her medical condition. Findings: The reviewer found that in this case, capsule endoscopy is medically necessary to evaluate abdominal pain in this patient with prior cancers and history of possible mass on imaging. This was not seen on subsequent imaging. The complete small intestine cannot be examined during endoscopy or enteroscopy. Capsule endoscopy is more sensitive for small intestine mass than imaging (which was negative). According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, evaluation for suspected small intestinal tumors, which this patient has had in the past, is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging.

Where the denial was upheld

Physician 1: The patient is a 60-year-old woman with Crohn’s disease who was recently diagnosed with active mucosal disease of her small bowel by capsule endoscopy. She was subsequently treated with steroids and Remicade to induce remission. She has requested authorization and coverage for another capsule study to assess disease activity. The submitted records indicate she currently has few if any symptoms suggestive of active Crohn’s disease. The Health Plan has denied coverage for the requested endoscopy on the basis it is considered investigational for evaluation of the patient’s condition. While capsule endoscopy has been shown to be a sensitive test for diagnosing Crohn’s disease and has gained widespread acceptance as an initial diagnostic test in this regard, there are no data justifying its use as a tool to guide therapeutic decisions.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for capsule endoscopy. In this case, the patient has had iron-deficiency anemia, and an upper endoscopy and colonoscopy were unrevealing. The American Gastroenterological Association (AGA) guidelines for the gastrointestinal evaluation of iron-deficiency anemia notes that in uncomplicated asymptomatic patients with iron deficiency anemia and negative bidirectional endoscopy, the AGA suggests a trial of initial iron supplementation over the routine use of video capsule endoscopy. Researchers report, “Positive findings on video capsule endoscopy led to subsequent endoscopic interventions only in a small percentage of patients with iron deficiency anemia. Anemia improved and resolved equally whether there were video capsule endoscopy findings.

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 Capsule Endoscopy, then check the rights and deadlines that apply to your plan.