Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome (IBS). 
Treatment: Current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The insurer denied coverage for current procedural terminology (CPT) code 83993, calprotectin, fecal testing. 

The denial is overturned. 

This is a patient with a history of irritable bowel syndrome (IBS). She presented to the Gastroenterologist's (GI) office with complaints of bloating and gas pain. The physician recommended obtaining labs, obtaining a celiac screening, taking probiotics, and obtaining an endoscopy. Symptoms persisted.  The patient had fecal calprotectin testing in order to determine the source of symptoms. 

Fecal calprotectin levels can be correlated with disease activity in both Crohn's disease (CD) and ulcerative colitis (UC) and used in practice as an adjunctive tool in monitoring response to treatment, in conjunction with other laboratory tests and symptoms to arrive at clinical decisions, and thus can be deemed medically necessary in this case to optimize patient care. 

Calprotectin can be detected in tissue samples, body fluids, and stools and is zinc and calcium-binding protein from neutrophils and monocytes. It has been looked at as a marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. 

Furthermore, from UpToDate, "Fecal calprotectin levels are elevated in inflammatory intestinal diseases, and may be useful for distinguishing inflammatory gastrointestinal disease including IBD from noninflammatory causes of chronic diarrhea (such as functional abdominal pain)." 

From The American Journal of Gastroenterology, American College of Gastroenterology (ACG) Management of Crohn's Disease in Adults, the only mention of calprotectin is as follows.  "The presence of fecal leukocytes (or more recently abnormal fecal concentrations of calprotectin or lactoferrin) is an excellent way to confirm intestinal inflammation or inflammation in general; sometimes the presence of intestinal inflammation is also reflected in serum acute-phase reactants (e.g., elevated erythrocyte sedimentation rate, and elevated orosomucoid, and elevated C-reactive protein). 
 
From the American Gastroenterological Association (AGA) Institute Guidelines for the Identification, Assessment and Initial Medical Treatment in Crohn's Disease the only mention of calprotectin is as follows. It falls in the algorithm under "Assess inflammatory status" along with "Perform clinical lab testing" including, but not specific to any individual test, "CBC [complete blood count], CRP [c-reactive protein], CMP [comprehensive metabolic panel], Fecal calprotectin, ESR [Erythrocyte sedimentation rate]." 

Fecal calprotectin testing characteristics vary depending on the prevalence of IBD in the study population. In settings with a high prevalence of irritable bowel disease (IBD), such as a gastroenterology clinic, elevated fecal calprotectin (eg, >200 mcg/g) is useful for identifying patients with a high likelihood of having IBD. However, in settings with a low prevalence of IBD, such as a primary care setting, fecal calprotectin is more useful to rule out IBD (ie, if fecal calprotectin is normal [eg, <50 mcg/g (microgram per gram)], then IBD is unlikely). 

The carrier's denial of current procedural terminology (CPT) code 83993, calprotectin, fecal testing should be overturned.  It is more beneficial than any other standard treatments.