Endoscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an upper endoscopy with monitored anesthesia care. The submitted documentation supports the medical necessity of the requested upper endoscopy. Clinical guidelines recommend an endoscopy for investigation of upper gastrointestinal symptoms (such as heartburn or dyspepsia) when those symptoms are refractory to proton pump inhibitor therapy taken properly for four to eight weeks without response. American Society for Gastrointestinal Endoscopy (ASGE) guidelines state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. American College of Gastroenterology guidelines for gastroesophageal reflux disease recommend endoscopy if eight weeks of proton pump inhibitor therapy are ineffective.

The enrollee requested wireless capsule endoscopy. She has a history of abdominal pain. She experienced constant pain between her shoulder blades and frequent eructation and epigastric discomfort to the left upper quadrant, which did not respond to proton pump inhibitors or over-the-counter simethicone. An upper endoscopy was normal. A computed tomography scan noted a seven millimeter structure the distal ileum, which may represent bowel or a polyp. The gastroenterologist recommended a colonoscopy to evaluate the area in the distal ileum, with a follow-up capsule endoscopy. The wireless capsule endoscopy noted no evidence of a small bowel lesion or polyp, but detected a small foreign body in the distal small bowel. The gastroenterologist indicates the procedure was necessary due to the lesion on the distal ileum noted on the computed tomography scan.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for esophagogastroduodenoscopy (EGD) with anesthesia for the upper gastrointestinal endoscopic procedure. The Clinical Guidelines Committee of the American College of Physicians recommend endoscopy for investigation of upper gastrointestinal symptoms, such as dyspepsia or gastroesophageal reflux disease (GERD), when those symptoms are refractory to proton pump inhibitor (PPI) therapy taken properly for four to eight weeks without response. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is generally indicated if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nasopharyngoscopy balloon dilation of the bilateral eustachian tubes. Standard medical therapies for the treatment of eustachian tube dysfunction include a trial of intranasal steroid therapy and/or oral glucocorticoids. The most widely accepted standard surgical treatment for eustachian tube dysfunction is myringotomy, with or without tube insertion, which is regarded as relatively safe and effective.

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