Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gastrointestinal pathogen panel laboratory testing rendered on three dates. Based on the available documentation, this patient presented with diarrhea with a history of GERD. The patient underwent gastrointestinal pathogen panel laboratory testing on three dates. In this clinical setting, the initial gastrointestinal polymerase chain reaction pathogen panel performed was supported as likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the Infectious Diseases Society of America (IDSA) guidelines for acute diarrhea, certain pathogens can cause protracted diarrhea and cannot be detected with commonly used tests but can be found with nucleic acid amplification tests. According to the American College of Gastroenterology (ACG) guidelines for the management of acute diarrhea, traditional methods of diagnosis (bacterial culture, microscopy with and without special stains and immunofluorescence, and antigen testing) fail to reveal the etiology of the majority of cases of acute diarrheal infection. The ACG noted further that, polymerase chain reaction testing can be far more sensitive in clinical testing for the detection of certain pathogens, as in this patients case. Per the patients records, the first test showed Clostridioides difficile toxin. The testing on subsequent dates is not supported, as there is no documented ongoing diarrhea before those tests were performed, and guidelines for the management of Clostridioides difficile do not recommend gastrointestinal pathogen panel repeatedly after diagnosis to assess for resolution. Consistent with this support, the gastrointestinal pathogen panel laboratory testing rendered on the first date was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the gastrointestinal pathogen panel laboratory testing on the second and third dates was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the gastrointestinal pathogen panel laboratory testing rendered on the first date was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the gastrointestinal pathogen panel laboratory testing on the second and third dates was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewers are experts 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.