Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - Heartburn.
Treatment: Esophagogastroduodenoscopy (EGD) (procedure code 43239).
The insurer denied Esophagogastroduodenoscopy (EGD) (procedure code 43239) for medical necessity. 
The denial is upheld. 

The patient at time of presentation is a female who had an esophagogastroduodenoscopy (EGD). Progress note describes heartburn when she eats dinner late. There was no abdominal pain, vomiting, or nausea, and stool was normal. Her medications include Protonix 40 milligrams (mg). Her body mass index (BMI) was 21. The physical exam had no abnormalities. The impression was reflux, bloating, and an anti-reflux diet was recommended. She was told to avoid late meals or snacks.
Progress note described heartburn, reflux, and she had tried omeprazole with no success. The dose and the duration of the omeprazole trial was not documented. She has burping and bloating. She lost weight after coronavirus 2019 (COVID-19) infection and now was slowly gaining it back. Her medications did not include anti-acids. Her BMI was 20.1 with a normal physical exam. She was advised to have an endoscopy and to maintain an anti-reflux diet.
At issue is the medical necessity of Diagnostic Esophagogastroduodenoscopy (EGD).

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Diagnostic Esophagogastroduodenoscopy (EGD) is not medically necessary for this patient.
This request for an EGD was not medically necessary. There is no documentation of failing an adequate dose and duration of a proton pump inhibitor to treat reflux. There was no documented complicated reflux such as bleeding, vomiting, weight loss, stricture, or dysphagia. The notes describe a weight gain since a COVID-19 infection in the past. There was no concern for cancer or obstruction. The dose and duration of omeprazole therapy that was given to her by her private physician was not documented.
The clinical guideline criteria to perform an EGD were not met. There were no reflux symptoms that persisted after appropriate trial of therapy for at least two months. No vomiting, no age greater than 50, no unexplained dysphagia, no suggestion of structural disease such as anorexia, weight loss, or persistent nausea. No postoperative bariatric surgery evaluation. No bleeding, no anemia, no malabsorption, no imaging showing a lesion that required further clarification, no suspected portal hypertension, or no caustic ingestion.
According to the most recent American College of Gastroenterology (ACG) practice guidelines, "We suggest that patients greater than or equal to (>=) 60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high-risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age. Alarm features should not automatically precipitate endoscopy in younger patients, but this should be considered on a case-by-case basis. We recommend patients less than (<) 60 years of age have a non-invasive test Helicobacter pylori and treatment if positive. Those that are negative or do not respond to this approach should be given a trial of proton pump inhibitor (PPI) therapy. If these are ineffective tricyclic antidepressants (TCA) or prokinetic therapies can be tried. Patients that have an endoscopy where no pathology is found are defined as having functional dyspepsia (FD). Helicobacter pylori (H. pylori) eradication should be offered in these patients if they are infected. We recommend proton pump inhibitor (PPI), TCA and prokinetic therapy (in that order) in those that fail therapy or are H. pylori negative."
Therefore, the requested health service/treatment of Diagnostic Esophagogastroduodenoscopy (EGD) is not medically necessary.