Esophagogastroduodenoscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient was noted to have atrophic gastritis with intestinal metaplasia but no dysplasia, and a history of adenomatous colon polyps. She was being treated with pantoprazole. The patient underwent an esophagogastroduodenoscopy (EGD) for atrophic gastritis. This revealed an irregular Z-line, mild atrophic gastritis in the gastric body and fundus, and a normal duodenum. Biopsies showed intestinal metaplasia in the antrum but not the fundus. Per the grievance and appeals review form, the patient was concerned about her risk for cancer due to her brother’s history of esophageal cancer. The patient has requested reimbursement for the esophagogastroduodenoscopy (EGD) procedure (CPT 43239). The Health Plan denied the request and reported that the service at issue was not medically necessary for the evaluation of this patient.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esophagogastroduodenoscopy (EGD) procedure (CPT code 43239) and colonoscopy procedure (CPT code 45380). The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that EGD is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. In this case, the patient has failed proton pump inhibitor therapy, with persistent heartburn. Thus, the patient meets the ASGE criteria for evaluation with EGD. In addition, the ASGE supports the use of colonoscopy for evaluation of this patient’s symptoms. The ASGE guidelines state that a colonoscopy is appropriate “as the initial method for evaluation, as an alternative to radiographic studies” for unexplained abdominal pain to rule out disease.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested reimbursement for an esophagogastroduodenoscopy (EGD) and monitored anesthesia care (MAC) along with an approved colonoscopy. The EGD at issue is not supported by the submitted documentation. Clinical guidelines recommend an endoscopy for investigation of upper gastrointestinal symptoms when the symptoms are refractory to proton pump inhibitor that has been adequately attempted. Guidelines generally do not recommend endoscopy in individuals below standard age thresholds for the evaluation of dyspepsia. In this case, an attempt of proton pump inhibitor therapy was not documented before the EGD was completed. For these reasons, the esophagogastroduodenoscopy (EGD) was not indicated at the time it was performed. The MAC is also not supported by the provided documentation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for screening colonoscopy and esophagogastroduodenoscopy. Findings: The physician reviewer found that Guidelines from the American College of Gastroenterology (ACG) and guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) for Barrett’s esophagus recommend EGD with biopsies for dysplasia screening every three to five years in patients with non-dysplastic Barrett’s esophagus, as in this case. Per the records, this patient had an endoscopy previously. Thus, repeat EGD is not warranted for Barrett’s esophagus surveillance at this time.

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