Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain.

Treatment: Current procedural terminology (CPT) code 87507 (infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets).

The insurer denied coverage for current procedural terminology (CPT) code 87507 (infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets).

The denial is overturned.

The patient presented with a 2.5-week history of abdominal pain, non-bloody diarrhea, and vomiting. Given the prolonged nature of the patient's symptoms, the patient's treating physician ordered a gastrointestinal (GI) stool pathogen polymerase chain reaction (PCR) panel to guide treatment. The GI PCR was positive for enteroaggregative E. coli and antibiotics were prescribed. 

The insurer is denying coverage for the requested GI PCR testing as not medically necessary according to Cigna Coverage Policy 0530, nucleic acid pathogen testing, stating that the evidence that this test improves clinical outcomes is not strong enough. The insurer deems the test to be not medically necessary. 

The issues for consideration are whether the denial was valid and if the GI PCR test was a medical necessity for this patient.

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 a confirmatory culture.  Some evidence suggests that stool multiplex PCR tests can decrease healthcare utilization costs and antibiotic prescribing.

For this patient presenting with continued symptoms for > 2 weeks duration the literature cited by the treating team and the review from UpToDate support the use of GI PCR testing. In this specific case, the treating physician chose to treat the organism isolated from the GI PCR narrowing the choice of antimicrobial to use based on results. This test was medically necessary in this case and did guide treatment decisions as supported by the literature. 

This decision was rendered based on the materials submitted for review and was supported by the review from UpToDate cited above.

Reverse denial of coverage for Gastrointestinal stool pathogen PCR (GI PCR) testing.

Based on the above, the insurer's denial must be reversed. The health care plan did not 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 (infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets) is substantiated.