Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional Dyspepsia. 
Treatment: Esophagogastroduodenoscopy (EGD) (43239). 
The insurer denied the Esophagogastroduodenoscopy (EGD) (43239). 
The denial is overturned. 

The patient is a female. Her EGD (esophagogastroduodenoscopy) revealed gastritis, path showed chronic inactive gastritis. 

Per office visit, the patient was advised for trial of OTC (over the counter) PPI (proton pump inhibitor) and H2 (histamine H2-receptor) blockers and increasing the fibers. 

A review indicated that the EGD (esophagogastroduodenoscopy) was done for functional dyspepsia without documentation of trial of other therapy prior to that. 

Per the health plan's denial letter, EGD (esophagogastroduodenoscopy) was not necessary per policy and would be approved under the plan clinical criteria for people age 18 and over when used to diagnose certain conditions. These include, but are not limited to heartburn (reflux) after 2 months of treatment; persistent vomiting; feeling of fullness (dyspepsia) when age 50 or older; internal bleeding; problems during weight loss surgery; or suspicion of cancer or blockage. This denial is being appealed and is the subject of this review. 

Yes, the Esophagogastroduodenoscopy (EGD) (43239) was medically necessary. 
EGD (esophagogastroduodenoscopy) for diagnostic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications: 

A. Upper abdominal signs or symptoms: 
  1. Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy for 2 months or more; or
  2. Persistent vomiting of unknown cause; or
  3. New-onset dyspepsia in individuals 50 years of age of older; or
  4. Unexplained dysphagia or odynophagia; or
  5. Signs or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea;
  6. Postoperative bariatric surgery with persistent abdominal pain, nausea, counseling and behavior modification related to diet adherence;
  7. Recent or active gastrointestinal bleed; or
  8. Unexplained anemia due to either blood loss or malabsorption from a mucosal process; or
  9. To assess symptoms suspicious for inflammatory bowel disease (for example, bloody diarrhea); or
B. Intraoperative evaluation of anatomic reconstructions typical of modern evaluation of anastomotic leak and patency, fundoplication formation, pouch bariatric surgery; or
C. For confirmation and specific histologic diagnosis of radiologically demonstrated limited to:
  1. Suspected neoplastic lesion; or
  2. Gastric or esophageal ulcer; or
  3. Upper tract stricture or obstruction; or
D. Documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis; or
E. To assess acute injury after caustic ingestion; or
F. To identify upper gastrointestinal etiology of lower gastrointestinal symptoms, such as diarrhea, in individuals suspected of having small-bowel disease (for example, celiac disease); or
G. To evaluate persons with radiographic findings suggestive of achalasia. 

This patient in this case is a female, with new-onset dyspepsia in individuals 50 years of age or older. Therefore, the patient meets the above criteria. 

The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia, in a joint dyspepsia guideline, note, "We suggest that patients 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology."

Therefore, given the above the Esophagogastroduodenoscopy (EGD) (43239) was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 
The endoscopy was indicated in this patient's case, per the standard of care.