Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspepsia.
Treatment: esophagogastroduodenoscopy (EGD).
The insurer denied the esophagogastroduodenoscopy (EGD).
The denial is upheld.

The patient is a female patient who underwent an esophagogastroduodenoscopy (EGD) for complaints of functional dyspepsia.

No, the requested esophagogastroduodenoscopy is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient did not meet the generally accepted criteria for the provision of an EGD (esophagogastroduodenoscopy).

The ASGE (American Society for Gastrointestinal Endoscopy) defines this as follows:
A. Upper abdominal symptoms that persist despite an appropriate trial of therapy.
B. Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (eg, anorexia and weight loss) or new-onset symptoms in patients older than 50 years of age.
C. Dysphagia or odynophagia.
D. Esophageal reflux symptoms that persist or recur despite appropriate therapy.
E. Persistent vomiting of unknown cause.
F. Other diseases in which the presence of upper GI (gastrointestinal) pathology might modify other planned management.
Examples include patients who have a history of ulcer or GI (gastrointestinal) bleeding who are scheduled for organ transplantation, long-term anticoagulation or nonsteroidal antiinflammatory drug therapy for arthritis and those with cancer of the head and neck.
G. Familial adenomatous polyposis syndromes.
H. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
1) Suspected neoplastic lesion.
2) Gastric or esophageal ulcer.
3) Upper tract stricture or obstruction.
I. GI (gastrointestinal) bleeding:
1) In patients with active or recent bleeding.
2) For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI (gastrointestinal) source or when colonoscopy does not provide an explanation.
J. When sampling of tissue or fluid is indicated.
K. Selected patients with suspected portal hypertension to document or treat esophageal varices.
L. To assess acute injury after caustic ingestion.
M. To assess diarrhea in patients suspected of having small-bowel disease (eg, celiac disease).
N. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (eg, electrocoagulation, heater probe, laser photocoagulation, or injection therapy).
O. Removal of foreign bodies.
P. Removal of selected lesions.
Q. Placement of feeding or drainage tubes (eg, peroral, percutaneous endoscopic gastrostomy, percutaneousendoscopic jejunostomy).
R. Dilation and stenting of stenotic lesions (eg, with transendoscopic balloon dilators or dilation systems using guidewires).
S. Management of achalasia (eg, botulinum toxin, balloon dilation).
T. Palliative treatment of stenosing neoplasms (eg, laser, multipolar electrocoagulation, stent placement).
U. Endoscopic therapy of intestinal metaplasia.
V. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (eg, evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery).
W. Management of operative complications (eg, dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances).

The patient's diagnosis was functional dyspepsia. There was no notation that the patient failed appropriate treatment for an appropriate duration of time. Although the encounter note notes that "meds without help," there was no listing of which medications, duration or specific outcome for whatever medications were used. Also, the provider documented that the patient was advised about OTC (over the counter) H2 (histamine H2-receptor) agents and PPIs (proton pump inhibitors) in addition to the plan for endoscopy, further suggesting that the patient had not failed an appropriate treatment for an appropriate duration of time.

Therefore, given the above, the requested esophagogastroduodenoscopy is not medically necessary.