Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease
Treatment: Current Procedural Terminology (CPT) code 87507 infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g. ["for example"], Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets
The insurer denied coverage for CPT code 87507 infectious agent detection by DNA or RNA; gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets.
The denial is upheld.

The patient had a diagnosis of gastroesophageal reflux disease (GERD) and was complaining of nausea and upper abdominal discomfort. The patient had some improvement in their symptoms with Protonix. The patient also reported having 4-5 bowel movements a day which were formed and there was no rectal bleeding. A workup for celiac disease and H Pylori were negative. Since there was some right lower quadrant (RLQ) abdominal pain and increased frequency of bowel movements, the patient's physician wanted to rule out an infection and inflammatory bowel disease (IBD). Fecal calprotectin and a gastrointestinal (GI) polymerase chain reaction (PCR) were ordered. 

UpToDate has an article titled "Approach to the adult with acute diarrhea in resource-rich settings." Stool testing with stool cultures is a recommended test if a patient continues to have diarrhea for more than 1 week. The article also addresses multi-pathogen molecular panels. It states that a high degree of clinical correlation is necessary when interpreting results of molecular testing since these assays detect genetic material which does not always indicate infection with a viable organism. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel, should be submitted for confirmatory culture. 

Gastroenterology and Hepatology 2018 Nov; 14 (11): 646-652 has an article titled "Use and Interpretation of Enteropathogen Multiplex Nucleic Acid Amplification Tests in Patients With Suspected Infectious Diarrhea." The article states that this testing cannot differentiate between true infection and carrier states. The interpretation of the test requires acknowledging the limitations of the tests and exercising clinical judgment. More studies are needed to establish the cost effectiveness and their impact on antibiotic stewardship and clinical outcomes. 

The stool testing for infectious disease by PCR has been denied by the insurance company. The medical literature has shown that this test has limitations in its clinical use. If there was a concern about an active bowel infection, stool culture and testing for ova and parasites could have been done. There was a borderline calprotectin test which may need further evaluation. However, the stool for infectious agents by PCR was not medically necessary. The health care plan acted reasonably and with sound medical judgment. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for Current Procedural Terminology (CPT) code 87507 infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g. ["for example"], Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets is not substantiated.