Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Diagnostic Testing. 
The insurer denied Diagnostic esophagogastroduodenoscopy (EGD). 
The denial is upheld. 

The patient is a female who had an esophagogastroduodenoscopy (EGD) performed. The EGD stated there was epigastric pain. The results showed reflux with esophagitis, and superficial gastritis. The plan was for omeprazole 20 milligrams (mg) a day. Biopsy of the stomach showed mild chronic gastritis, no dysplasia, no helicobacter (H.) pylori. The outpatient medications prior to the procedure were listed as atorvastatin, hydrochlorothiazide, and cod liver oil. The abdomen was benign. The doctors progress note described a family history of colon cancer, pain in the upper abdomen, body mass index (BMI) was 31.8 and plan was for a colonoscopy, and computed tomography (CT) of the abdomen.

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) was not medically necessary for this patient.
This patient did not have a documented failure of proton pump inhibitors which is the standard approach to reflux/upper epigastric complaints. There were no documented alarm symptoms such as iron deficiency anemia, weight loss, vomiting, dysphagia, or weight loss.
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...We recommend patients less than (<) 60 years of age have a non-invasive test for 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). 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."
No alarm symptoms were documented in this case necessitating an EGD. There was no high risk for cancer, bleeding, or failed PPI therapy. Miwa described, "The revised guidelines have two major features. The first is the new position of endoscopy in the flow of functional dyspepsia (FD) diagnosis. Whereas previously organic disease had to be excluded by endoscopy to diagnose FD (the disease name "functional dyspepsia" could not be used for national insurance billing unless endoscopy had been performed), the revised guidelines specify that endoscopy should be performed in all cases where organic disease is suspected...Formerly, endoscopy had been required for a diagnosis of FD even in patients who were negative for Helicobacter pylori, patients as young as 20 years of age, and patients who had been screened for stomach cancer in the previous 6 months. The revised guidelines, however, have been changed to specify that rather than endoscopy being performed indiscriminately, the need for it should be determined for each patient depending on the patient's physical findings, history (family, disease, tests), and other relevant factors. By eliminating unnecessary tests, this change is expected to bring many benefits, including reducing the physical and financial burden on patients, allowing their treatment to begin sooner, and helping control the cost of medical care to society." This patient did not have prior H. Pylori testing or alarm symptoms/signs to require EGD.
Therefore, the requested health service/treatment of Diagnostic esophagogastroduodenoscopy (EGD) was not medically necessary.