Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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. The American College of Gastroenterology (ACG) guidelines for GERD recommend endoscopy if eight weeks of PPI therapy are ineffective. The ACG and Canadian Association of Gastroenterology (CAG) guidelines on the management of dyspepsia state, We do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal neoplasia. In this case, there was no documentation that the patients symptoms were refractory to continuous PPI therapy for at least four weeks. In this clinical setting, an EGD with biopsies was not medically indicated for evaluation of the patients epigastric pain. According to the American Society of Anesthesiologists (ASA) guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care may be considered for prolonged or painful procedures. These may include procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. The guidelines further note that monitored anesthesia care may be considered for patients with anticipated intolerance to standard sedatives, or with increased risk for airway obstruction. According ASGE practice guidelines, consciousness during endoscopic procedures, unlike in surgery, is acceptable and is the goal during most procedures. In this case, the submitted records did not document that the patient met these criteria or other criteria found in current medical literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater years, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. Therefore, EGD with anesthesia for the upper gastrointestinal endoscopic procedure was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.