Appeal type: Experimental/Investigational
Decision: Overturned

This is a young male patient with a history of abdominal pain and bloody stools.  There was concern for inflammatory bowel disease; laboratory work up was performed that included fecal calprotectin.  The use of fecal calprotectin is established in the medical community and is well supported by peer reviewed literature.  Fecal calprotectin is a useful screening tool in pediatric patients with chronic gastrointestinal complains.  In contrast to routine blood testing, there is strong evidence that screening with fecal calprotectin in pediatric patients with undifferentiated abdominal pain has high sensitivity and can improve the diagnostic yield of the invasive procedures.  In a meta-analysis, the pooled sensitivity of fecal calprotectin was 98% in the diagnostic work-up of pediatric inflammatory bowel disease (IBD), supporting its use as a screening lab for patients with symptoms suggestive of IBD.  FC has a high sensitivity and a modest specificity during the diagnosis of suspected pediatric IBD.  This is all you need from a screening tool.  It is not meant to be confirmatory (Henderson, P., et al., 2014). 

In addition, data has recently been published demonstrating the utility of fecal calprotectin to reduce the number of endoscopies in the evaluation for suspected pediatric IBD.  "The findings of this cohort study with historical controls suggest that screening with the calprotectin stool test may reduce the number of children that is unnecessary exposed to endoscopic procedures.  There seems no value in exposing children to endoscopy when stool calprotectin levels are <50 g/g" (Heida, A., et al., 2016). 

Additional data has been published demonstrating the effectiveness of using fecal calprotectin to better identify patients who were being considered for referral to a pediatric gastroenterologist (Holtman, G. A., et al., 2016). 

The clinical practice guidelines support the use of fecal calprotectin to diagnose and monitor inflammatory bowel disease.  The findings of this study suggest that a positive FCal result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD.  A negative FCal result is likely to be a true negative, which safely rules out IBD in children in whom a primary care physician considers referral to specialist care" (Turner, D., et al., 2018).

The use of this test is also supported by North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN).  An advocacy letter is published on the NASPGHAN website to assist physicians in getting this test covered (NASPGHAN, 2016).

Based on the patient's medical records and the available scientific evidence, the use of fecal calprotectin is likely to be more beneficial when compared to other blood and stool tests as it has better sensitivity and specificity in identifying inflammatory bowel disease.  Fecal calprotectin has been shown to reduce the number of endoscopes done in the evaluation of pediatric patients with chronic gastrointestinal complains. 

The carrier's denial of coverage for Fecal Calprotectin to screen for IBD should be reversed.