Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Abdominal pain with blood per rectum.
Treatment:  Current procedural terminology (CPT) code 83993 [calprotectin, fecal].
The insurer denied coverage for CPT code 83993 [calprotectin, fecal].  
The denial is upheld.

This case involves a child who complained of rectal bleeding, diarrhea, and abdominal pain and underwent fecal calprotectin testing.  Records stated the patient had a family history of Crohn's disease and there were concerns of possible underlying inflammatory bowel disease.  The visit note stated the patient had a history of bloody mucus in her stool, stool frequency increased over the last month.  Symptoms began a few months earlier.  The patient had a noted anxiety disorder and had been taking Prozac.  At the time of the visit, the patient was having bowel movements approximately 3 times a day with consistency varying.  The report stated that in addition to anxiety, the patient had a history of COVID-19 virus and chronic constipation.  She reported abdominal pain with the review of systems; negative for blood in the stool and vomiting.  Vital signs were stable.  Her examination was otherwise unremarkable.  The fecal calprotectin report was normal.  

Scientific evidence in peer-reviewed literature supports that fecal calprotectin has been used for diagnosing pediatric patients with ulcerative colitis and Crohn's disease.  The results can directly affect a treatment plan, and thus improve the patient's health outcome.

The current procedural terminology (CPT) code 83993 [calprotectin, fecal] has final approval from the appropriate regulatory bodies for diagnosing ulcerative colitis and Crohn's disease in adults and pediatric patients.

This patient is not a good candidate for current procedural terminology (CPT) code 83993 [calprotectin, fecal].

The current procedural terminology (CPT) code 83993 [calprotectin, fecal] is not the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The United Healthcare Commercial Medical Policy states that fecal measurement of calprotectin is proven and medically necessary for establishing the diagnosis or management of Crohn's disease and ulcerative colitis.  This testing has been found to be unproven and not medically necessary for establishing the diagnosis or for management of any other condition.  

A more accurate history of the patient's symptoms would have been beneficial in determining the medical necessity for the fecal calprotectin testing.  The physician did not elaborate on the frequency and duration of bleeding, no description of whether this was bright red blood, dark blood, black stool, or if there were other possible causes of changes in the patient's bowel habits.  Furthermore, the physician indicated that there were pending results from a stool culture and C. difficile.  It would be prudent to first determine the results of these studies before sending the patient for more advanced testing.  Based upon the provided documentation, the (CPT) code 83993 [calprotectin, fecal] was not medically necessary.

In summary, the denial of current procedural terminology (CPT) code 83993 [calprotectin, fecal]  and coverage for the requested service should be upheld. This treatment is not 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.