Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-bloody Diarrhea 

Treatment: Current Procedural Terminology (CPT) code 87507 

The insurer denied coverage for Current Procedural Terminology (CPT) code 87507 

The denial is upheld 

The patient is a child with a past medical history of enuresis, fine motor delay, speech delay, reactive airway disease, allergic rhinitis and recent COVID (coronavirus) infection that presented with a 4-day history of abdominal pain and non-bloody diarrhea. By report there were no sick contacts, change in diet, history of dinning out, recent travel, recent antibiotic use, or known re-exposure to COVID-19. Clinically there was no fever, weight loss, upper respiratory infection (URI) symptoms, decreased appetite, nausea, vomiting, decreased urine output or rash. Physical exam was normal. The patient's treating physician ordered a gastrointestinal stool pathogen polymerase chain reaction (PCR) panel to guide treatment. The gastrointestinal (GI) PCR was positive for enteropathogenic Escherichia coli (E. coli). There was no notation whether this result was treated with antibiotics. 

This child presented with acute diarrhea that was present with abdominal pain less than 2 weeks (physician notes states 4 days, mother's appeal states 10 days). According to a review of the approach to diarrhea in resource rich countries from UpToDate the authors note the following: 

The main reason for microbiologic stool testing in these patients with acute diarrhea is to identify a potential bacterial pathogen that would inform the potential for complications and treatment decisions. 

Multipathogen molecular panels - Some laboratories have access to multiplex stool tests; these use molecular techniques to test for a panel of many different pathogens (bacterial, viral, and parasitic) performed on diarrheal stool samples as well as rectal swabs in some cases. It is important for clinicians to understand which technology is being used for the diagnosis of diarrheal pathogens in their clinical laboratory, since test performance and result interpretation depend, in part, on the test employed. 

Careful clinical correlation is necessary when interpreting results of molecular testing, since these assays detect genetic material (which does not always reflect infection with a viable organism), and identification of more than one pathogen is not uncommon. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel (or other culture-independent test) should be submitted for confirmatory culture; this is important for public health purposes and for susceptibility testing. If the original specimen was a rectal swab, an additional stool specimen may be warranted to perform confirmatory culture.  Some evidence suggests that stool multiplex PCR tests can decrease health care utilization costs and antibiotic prescribing. 

In an article by Cotter et al. (2021), the authors concluded that the GI PCR testing led to increased pathogen detection and faster results. This translated into improved outcomes for only a small subset of patients, suggesting that unrestricted use leads to low-value care. Similar to other novel rapid diagnostic panels, there is a critical need for diagnostic stewardship to optimize GI PCR testing.

For this patient presenting with a relatively short duration of acute diarrhea without predisposing factors and without complications the literature cited above does not support the use of GI PCR testing. This test was not medically necessary in this case and may not have guided treatment decisions as supported by the literature. This decision was rendered based on the materials submitted for review and the references cited above. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Current Procedural Terminology (CPT) code 87507 is not substantiated.