Colonoscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a colonoscopy and monitored anesthesia care. The submitted documentation supports the medical necessity of the requested colonoscopy for evaluation of this patient. A review of the record reflects that the patient has been diagnosed with ulcerative colitis. Clinical guidelines from the American College of Gastroenterology (ACG) indicate that colonoscopy for dysplasia screening is recommended every one to three years in patients that have been diagnosed with ulcerative colitis for over eight years. Other studies have reported longstanding recommendations for a colonoscopy every one to two years in those patients. In this case, the patient has a history of active ulcerative colitis. Further, a review of the record establishes that the patient has not undergone a colonoscopy for a few years.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for colonoscopy and urgent and immediate scheduling of the colonoscopy. One study evaluated the data on diagnostic yield of colonoscopy in young adult patients with lower gastrointestinal (GI) symptoms. The authors concluded that for patients with lower GI symptoms, the need for endoscopic evaluations should be determined clinically on a case-by-case basis. Another study found that chronic diarrhea and abdominal pain, rectal bleeding, and constipation were major indications for colonoscopy performance in quadragenarian and younger patients. The authors noted that rectal bleeding was associated with colorectal cancer development in young patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for hospitalization services and prospective authorization and coverage readmission to an acute care hospital to receive the following services: obstetrics and gynecology (ob/gyn) physician while inpatient; nephrologist, while inpatient; magnetic resonance imaging (MRI) scan of abdomen and pelvis, while inpatient, and colonoscopy while inpatient; double balloon endoscopy while inpatient, parasite testing while inpatient, and work up for definitive diagnosis while inpatient. Findings: The physician reviewer found that the documentation provided fails to demonstrate the medical necessity for the services at issue.

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonoscopy for treatment of the enrollee, who has been diagnosed with delusional parasitosis. Findings: The physician reviewer found that the records fail to demonstrate the medical necessity of the requested services. Delusional parasitosis is a rare disorder in which patients have a delusion that they are infected by parasites or other living organisms. Patients commonly present for general medical or dermatologic care (rather than psychiatric care) with a fixed, false belief of infestation. They typically describe pruritus and frequently have excoriations from scratching. They often have a history of dermatologic complaints. In this case, the patient has presented several times with complaints of abdominal pain, constipation and witnessed “worms” infecting her stool.

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