Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:		

This case involves a female with a history of Crohn's disease of both small and large intestine with other complications, inflammatory bowel disease (IBD), iron deficiency, vitamin B deficiency, xerotic eczema, Staphylococcus infection, anxiety, depression, hypothyroidism, migraine headaches, and scoliosis. The patient had been on various medications and her quality of life in the last several years has been worsened due to excessive episodes of diarrhea and fecal incontinence.  The patient had undergone endoscopy and colonoscopy, which revealed worsening Crohn's disease.  The patient had seen endocrinology.  The patient felt generally okay, but in the prior week, she had 4 episodes of fecal incontinence over 4 days.  The patient stated she made some "nonideal dietary choices"-corn.  The patient had a frequency of these accidents that have decreased significantly overall.  The patient's energy was low and she was not sleeping well.  It was hard to tell if the medical marijuana was helping.  The patient had tried various tablets, vape, sublingual, and suppository.  The patient's elimination pattern was described as 10 times per day.

This case was previously denied as the quantity and quality of data in the current peer-reviewed scientific medical literature was inadequate to establish the clinical utility and efficacy of the treatment for the patient's diagnosis.

The provider appeal letter indicated the patient had a history of IBD/Crohn's disease.  In an effort to evaluate her ongoing symptoms of diarrhea, both infectious and inflammatory still stool tests were sent. The inflammatory stool marker sent was calprotectin fecal 83993, a standardized inflammatory marker in the literature which is a biomarker utilized to determine the level of inflammation in inflammatory bowel disease patients. The provider noted that the diagnosis code was wrong and should have been K50.119, Crohn's disease of the large intestine and K50.818, Crohn's disease of both small and large intestine.

According to referenced literature the utilization of this testing is appropriate to assess inflammatory bowel disease activity as well as diagnosed inflammatory bowel conditions. The use of the requested testing is supported to monitor the response to treatment as elevated fecal calprotectin levels correlate with active disease which may help determine which patients require additional testing such as a colonoscopy. The documentation indicated the patient does have a history of Crohn's disease and has received multiple treatments. The patient has undergone a colonoscopy with worsening findings. The utility in this setting was proven as the testing is a non-invasive, inexpensive way of monitoring inflammatory activity, without subjecting the patient to repeated colonoscopies. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes, as with the results, additional or continued treatment may be supported.  The patient is a good candidate for the fecal calprotectin testing, and it is the best available testing for this patient at this time as it is less invasive for the patient, may be repeated as needed and is supported by literature. The requested service is likely to be more beneficial than any of the standard testing/procedures for this patient, such as a repeat colonoscopy.

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 83993 Calprotectin, fecal provided for diagnosis code E 53.8 should be reversed.