Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 58-year-old woman with a reported history of chronic diarrhea and spastic colitis for 20 years. There is no documented history of abdominal pain, weight loss or loss of appetite. The patient has a past medical history of cervical cancer, asthma, peptic ulcer and gallbladder sludge. She has had a flexible sigmoidoscopy and barium enema in the past. The patient was given the option of conventional colonoscopy versus CT colonography (also known as virtual colonoscopy) and elected to undergo the latter. The results of the virtual colonoscopy were normal. At issue is whether the virtual colonoscopy at issue was likely to be more beneficial for evaluation of the patients medical condition than any available diagnostic modality.Virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both two-dimensional and three-dimensional views of the colon and rectum using data derived from computed tomography. This imaging modality has been explored as an alternative to conventional endoscopic colonoscopy, particularly as an alternative screening tool for colorectal cancer. Although virtual colonoscopy does not require sedation and requires less time for completion, the study requires the same bowel-cleansing preparation as conventional colonoscopy as well as gas insufflation of the intestine, which may be associated with patient discomfort. The Food and Drug Administration approved virtual colonoscopy technology in 1995. Virtual colonoscopy is being proposed as a method for non-invasive evaluation of the colon for colon cancer screening. However, several recently published studies that tested the efficacy of virtual colonoscopy to detect polyps have shown different results. In the multicenter U.S. study (Pickhardt, et. al.), 1233 asymptomatic average-risk adults (mean age, 58) underwent virtual colonoscopy followed immediately by conventional fiberoptic colonoscopy. Of 59 advanced lesions, virtual colonoscopy identified 54 and blinded conventional colonoscopy identified 52. However, another recently published study (Cotton, et. al.) showed virtual colonoscopy to have poor sensitivity in the detection of colon polyps. In this study, the sensitivity of virtual colonoscopy in detecting a polyp of 1cm in size or greater was only 55%. The findings from a recently published meta-analysis of studies comparing colonoscopy to virtual colonoscopy were that inconsistencies in the performance of virtual colonoscopy preclude it from being considered an appropriate test for colon cancer screening.Although virtual colonoscopy appears to be a promising imaging technique, a larger body of literature must be accumulated to warrant the development of rational, evidence-based algorithms in order to determine the precise operating characteristics of virtual colonoscopy in different settings. Based upon the information set forth above, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2:  The patient is a 58-year-old female with a history of chronic diarrhea, most likely due to IBS. Her gastroenterologist was concerned that the patient might have colitis or possible malabsorption and therefore ordered a CT colonography study. The Health Plan has denied reimbursement for the study on the basis that it is investigational in nature.CT colonography was not medically indicated in this clinical setting. Given the differential diagnosis, endoscopic visualization of the mucosa was needed. Flat mucosal diseases such as microscopic colitis cannot be seen by CT. Biopsies are appropriate in this setting to rule out microscopic colitis. The use of CT colonography added no clinical value to the evaluation and care of this patient. Therefore, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3:  The patient is a 58-year-old woman with a history of rectal bleeding and intermittent diarrhea. Based on the submitted information, it appears the patient never had a colonoscopy. She underwent a CT colonography in December 2005, the results of which were normal. The Health Plan has denied the patients request for reimbursement for the CT colonography on the basis that the efficacy and superiority of the diagnostic procedure remain unproven.CT colonography is not the standard of care or the community standard for screening or diagnostic purposes. The patient could have been appropriately evaluated with a colonoscopy. There is no evidence a CT colonography added clinical value to the care and management of this patients abdominal complaints. Therefore, I have determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.