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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repeat hepatobiliary iminodiacetic acid (HIDA) scan, repeat impedance test, repeat endoscopy, and/or repeat manometry. Findings:  The physician reviewer found that repeat impedance test, repeat endoscopy, and/or repeat manometry. The requested repeat pH-impedance testing is supported as medically necessary for evaluation of this patient. The impedance study can be used to evaluate intra-esophageal liquid movements to assess the patients gastroesophageal reflux of acidic and alkaline fluid (Ward, et al.; Cho, et al.). The American College of Gastroenterology (ACG) guidelines for the management of patients with GERD state that reflux monitoring can be performed by pH-impedance testing (Katz, et al.). Per the ACG guideline, the requested pH-impedance testing can be useful in the evaluation of endoscopy-negative patients with typical reflux symptoms that are refractory to proton pump inhibitor therapy. A repeat pH-impedance study could result in a different outcome or interpretation, which may change the management of reflux disease in this patient with ongoing reflux symptoms despite long-term proton pump inhibitor therapy. For these reasons, the requested repeat impedance test is medically necessary for the evaluation of this patient. In addition, the requested repeat manometry is also supported as medically necessary for this patient. The ACG reported that, We recommend high-resolution manometry before antireflux surgery or endoscopic therapy to rule out achalasia and absent contractility (Katz, et al.). In this patients clinical setting, anti-reflux surgery is being considered. The results of esophageal manometry may change management by predicting the likelihood of success of surgical intervention. Thus, the requested repeat manometry is medically necessary for this patient. However, the requested repeat endoscopy is not medically necessary for this patient. The American Society of Gastrointestinal Endoscopy (ASGE) guidelines recommend endoscopy for investigation of upper gastrointestinal symptoms such as GERD when those symptoms are refractory to proton pump inhibitor taken properly for four to eight weeks without response (Early, et al.). Although the patients symptoms have been refractory to treatment with proton pump inhibitor therapy, the patient has undergone evaluation with multiple esophagogastroduodenoscopies. On review of the records, a repeat endoscopy is not likely to demonstrate new findings that have not been seen on the previous studies. Similarly, a repeat HIDA scan is not medically necessary for this patient. As noted in the medical literature, a HIDA scan can be used to diagnose enterogastric reflux, which is suspected as a cause for this patients bile reflux. However, the available documentation reports a previous HIDA scan, interpreted to show enterogastric reflux, with further interpretation of the HIDA scan pending. Based on the records provided for review, there is no evidence that prior test results were unable to be interpreted to support an indication for repeat HIDA scan. Therefore, a repeat HIDA scan is not indicated for this patient. Given these findings, the requested repeat impedance test and esophageal manometry are medically necessary for evaluation of this patient, while the requested repeat HIDA scan and repeat endoscopy are not medically necessary. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.