Scoping Procedure denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested wireless capsule endoscopy for evaluation of the enrollee’s medical condition. Findings: Two physician reviewers found that there is a concern that Crohn’s disease is affecting the small intestine and causing the patient’s symptoms. Imaging has been unremarkable, and there is concern about performing endoscopy or colonoscopy due to anesthesia issues with prior procedures. Wireless capsule endoscopy evaluates the small intestine and has proven useful for indications other than bleeding, including detection of occult Crohn’s disease. The American Society for Gastrointestinal Endoscopy guidelines for endoscopy in inflammatory bowel disease recommends the use of capsule endoscopy in the diagnosis of Crohn’s disease (Leighton, et al).

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.

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.

Physician 1: The patient is a 58-year-old woman with a reported history of chronic diarrhea and “spastic colitis” for 20 years. There is no documented history of abdominal pain, weight loss or loss of appetite. The patient has a past medical history of cervical cancer, asthma, peptic ulcer and gallbladder sludge. She has had a flexible sigmoidoscopy and barium enema in the past. The patient was given the option of conventional colonoscopy versus CT colonography (also known as virtual colonoscopy) and elected to undergo the latter. The results of the virtual colonoscopy were normal.

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