Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

Diagnosis: chronic diarrhea

Treatment: Infectious agent detection by nucleic acid (Deoxyribonucleic acid (DNA) or Ribonucleic acid (RNA)); gastrointestinal pathogen (Clostridium difficile, E. (Escherichia) 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 infectious agent detection by nucleic acid (Deoxyribonucleic acid (DNA) or Ribonucleic acid (RNA)); gastrointestinal pathogen (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 overturned

This case involves an adult who was seen for bowel irregularity and diarrhea. The patient reported that the patient became sick with diarrhea after going on a trip out of the country for 3.5 weeks. The report stated that the patient also caught Coronavirus-19, which made the diarrhea worse with the patient also developing vomiting. The patient saw the primary care physician upon return to the states and had the blood checked and stool studies completed. Ova (eggs) and parasite exam, stool culture, Giardia were negative. Blood work was normal except for ALT (Alanine transaminase) at 35. The patient was advised to stay on a BRAT (banana, rice, apple sauce, and toast) diet, but still developed intermittent bouts of diarrhea after eating. The patient was unable to confirm a pattern but endorsed good relief with Imodium.  There was no blood in the stools, no fevers, and no abdominal pain. The patient decided to seek further evaluation given the lingering diarrhea, which had ensued for almost 5 weeks. The examination was unremarkable, and the patient was assessed with acute diarrhea, abnormal liver enzymes, and was recommended for additional work-up. This included ova plus parasite exam, fecal count, qualitative, white blood cell count, stool, Clostridium difficile toxins A+B, EIA (enzyme immunoassay), fecal calprotectin, GI (gastrointestinal) bio fire PCR ((polymerase chain reaction) ) (22 pathogens) stool, and an abdominal ultrasound. The plan was to check stool studies first, with advisement to use Pepto-Bismol and Imodium as needed. The patient was advised to cut out dairy with suspected postinfectious IBS (irritable bowel syndrome) given the irregularity of the diarrhea. The patient received a notice of adverse determination regarding charges for infectious agent detection by nucleic acid, gastrointestinal pathogen, to include multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets.

This patient was a good candidate for infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (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 infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (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 was one of the best available treatments for this patient at this time.

Current medical literature notes that rapid and accurate diagnostic tools are needed for appropriate management of infectious diarrhea. Acute infectious gastroenteritis can be caused by viruses, bacteria, or parasites, resulting in a diarrheal illness that may be accompanied by fever, abdominal pain and/or cramping, hematochezia, nausea, and vomiting. In taking the patient's travel history into consideration, along with the duration that the patient had symptoms, additional work-up was appropriate given that the patient did not have a sufficient response to initial treatment. While the patient claims to respond favorably to Imodium, that medication is not intended for long-term use, and is only for treating symptoms, not curing the underlying issue. Although initial testing was negative for findings, this did not rule out all potential causes of the patient's condition. Evidence has shown that the proposed testing is not experimental or investigational and can help to determine which, if any, pathogens are causing diarrhea and other gastrointestinal problems. It was therefore determined that the testing was appropriate.

In summary, the denial of infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (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 and coverage for the requested service should be overturned. 

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments. 

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

The medical necessity for this testing is substantiated.