Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Abdominal pain with blood per rectum.
Treatment:  Current procedural terminology (CPT) code 83993 [calprotectin, fecal].
The insurer denied coverage for CPT code 83993 [calprotectin, fecal].  
The denial is overturned.

This is a child with anxiety who presented to pediatric gastroenterologist with rectal bleeding, mucoid diarrhea and abdominal pain. Of note, the mother and uncle both have inflammatory bowel disease. Given pediatrician's concern for inflammatory bowel disease, a fecal calprotectin was ordered. 

In this case, a young girl with family history of inflammatory bowel disease (IBD) presented with at least one-month history of rectal bleeding, change in bowel pattern and abdominal pain. Blood work and fecal calprotectin was obtained as an initial screener for inflammatory etiology in a reported attempt to avoid more invasive/unnecessary testing. Fecal calprotectin is a biomarker of intestinal inflammation and has been proposed as a noninvasive means to differentiate inflammatory versus non-inflammatory bowel disease (i.e., irritable bowel syndrome) when endoscopy with biopsy is being considered. For individuals who have a suspicion of IBD when endoscopy with biopsy is being considered who undergo fecal calprotectin testing to select patients who can forgo endoscopy, the evidence includes prospective and retrospective diagnostic marker accuracy studies and systematic reviews. 

Twenty-eight studies in a systematic review evaluated the diagnostic accuracy of fecal calprotectin in patients suspected of having IBD for whom non-inflammatory bowel disease, such as irritable bowel syndrome (IBS), remained a consideration. Studies have indicated that the test has a sensitivity of 93 percent (%) to 99% for IBD and a negative predictive value of 73% to 100% for intestinal inflammation. Out of 100 cases of suspected IBD, approximately 49 invasive tests would be avoided with 1 case missed (1). In another more recent meta-analysis, the investigators determined that out of 100 hypothetical patients, 18 patients with non-inflammatory disorder would undergo colonoscopy and 1 patient with IBD would be missed and not be referred for a colonoscopy. It was determined that incorporating a fecal calprotectin test into the regular diagnostic work up would reduce the need for colonoscopy by 66.7% (2). In another meta-analysis of adult and pediatric studies, the authors concluded that fecal calprotectin is a useful screening tool for identifying those patients who are most likely to need endoscopy for inflammatory bowel disease. This practice may result in improved outcomes for patients (3). Therefore, fecal calprotectin can be used to inform a decision of whether to proceed with endoscopy. The evidence may be sufficient to determine that the noninvasive marker (fecal calprotectin) results in an improvement in the net health outcome and avoids potential unnecessary, invasive procedures that have risks (bleeding, infection, perforation, anesthesia risk, etc.).

Given above, this patient was a good candidate for a screening fecal calprotectin given presenting symptoms and increased risk of IBD with considerations for other non-inflammatory gastrointestinal (GI) disorders. 

Obtaining fecal calprotectin level was the best available diagnostic option for this patient at the time of presentation. Fecal calprotectin was a more beneficial diagnostic test at the time of presentation as compared to more invasive and riskier endoscopy with biopsy.

In summary, the denial of current procedural terminology (CPT) code 83993 [calprotectin, fecal] and coverage for the requested service should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks not substantially increased over standard treatments.