Wireless Capsule Endoscopy denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wireless capsule endoscopy for evaluation of the enrollee’s abdominal pain. Findings: 2/3 of the physician reviewers found that the physician reviewer found this patient has had symptoms and biopsy findings suggestive of possible Crohn’s disease. Capsule endoscopy is useful for the diagnosis of Crohn’s disease or determination of the extent of disease activity, and has been demonstrated to be superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohn’s disease.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wireless capsule endoscopy (SmartPill Monitoring System) CPT code 91112 for evaluation of the enrollee’s gastroparesis. Findings: The physician reviewer found that The SmartPill wireless capsule endoscopy is U.S. Food and Drug Administration (FDA) approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. The device is recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, wireless capsule endoscopy has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and has not been demonstrated to be superior to gastric motility or colon transit testing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. On review of the available documentation, this patient presents with a history of abdominal pain, gastritis, and small sliding hiatal hernia. The patient’s provider has recommended valuation with wireless capsule endoscopy. As noted in the medical literature, wireless capsule endoscopy is recommended for the evaluation of patients for possible causes of small bowel bleeding, suspected Crohn’s disease, or abnormal small bowel imaging. One study noted that possible indications for small bowel capsule endoscopy include “obscure gastrointestinal bleeding, Crohn’s disease, small-intestinal polyps and tumors, and celiac disease”.

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