Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic abdominal pain.
Treatment: Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report.

The insurer denied coverage for the gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report.  The denial is overturned. 

This is a male patient with a history of gastritis and esophagitis. He has chronic right upper quadrant (RUQ) abdominal pain. There was an extensive work-up done. The patient's physician advised a capsule endoscopy.

The Wireless Capsule Endoscopy (WCE) is medically necessary and likely to be more beneficial than any of the standard treatments/procedures for this patient in this case.  The primary indications for WCE or Video Capsule Endoscopy (VCE) are for diagnoses of obscure gastrointestinal bleeding location in adults (including iron deficiency anemia), suspected Crohn disease, and small bowel tumors.  The procedure can be performed both in the ambulatory outpatient setting or inpatient for hospitalized patients.
 
VCE allows an expanded range of endoscopic examinations of the small bowel.  The clinical application of VCE is mainly for Obscure Gastrointestinal Bleeding (OGIB).  A small bowel tumor is one of the clinically significant diagnoses of VCE. Subsequent invasive interventions follow typically.
 
Small bowel tumors are detected with a frequency of around 4% with VCE in indications of OGIB, iron deficiency anemia, unexplained abdominal pain, and others. "Familial adenomatous polyposis, Peutz-Jeghers syndrome, melanoma, lymphoma, and neuroendocrine tumor with hepatic metastasis are the high-risk groups for small bowel tumors, and surveillance programs for small bowel tumors are needed" (Young Cheung, D., et al. 2016). VCE and radiological imaging have value in screening.
 
The diagnosis of small bowel tumors is rare in practice. Only 3% to 6% of all gastrointestinal neoplasms develop in the small intestine.  Over 40 different histological types of tumors are diagnosed.  Adenoma and mesenchymal tumors are the most common ones. Malignant tumors include, "neuroendocrine tumor, adenocarcinoma, lymphoma, and sarcoma in order of frequency" (Young Cheung, D., et al. 2016).  Metastatic small bowel tumors are known to be skin melanoma, colorectal cancer, prostate cancer, and lung and breast cancers.
 
Major indications for small bowel VCE are OGIB, suspicious small bowel Crohn disease, unexplained iron deficiency anemia, and unexplained abdominal pain.
 
Patients with Neuroendocrine Tumors (NET) of the small bowel often present with metastatic disease, and localization of the primary tumor still is a diagnostic challenge. VCE is an established method that improves the diagnostic evaluation of diseases of the small intestine. In patients with NET, wireless capsule endoscopy may be helpful in individual cases, but the general diagnostic value of this method may be limited due to frequent extraluminal growth of these tumors.
 
The requested procedure is likely to be more beneficial than any other existing standard health service.    

The carrier's denial of coverage for the gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report should be overturned.