Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Abdominal/Stomach Pain
Treatment: Lab Work/Blood Tests - Calprotectin fecal test
The health plan denied the Calprotectin fecal test as experimental/investigational. 
The health plan's determination is overturned.

This patient is a male. He has a history of abdominal pain and constipation. He also has occasional loose stools and weight loss.

At issue is whether the proposed health service of a Calprotectin fecal test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I overturn, in whole, the health plan's determination regarding the proposed health service.

Yes, the proposed test was more beneficial than the available alternatives.

The use of fecal Calprotectin (FC) 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% (percent) 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 [1].

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 unnecessarily exposed to endoscopic procedures. There seems no value in exposing children to endoscopy when stool Calprotectin levels are < [less than] 50 g/g (micrograms/gram)." [2]

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 [3].

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 FC result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD. A negative FC 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." [4]

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 physician get this test covered. [5]

Therefore, the requested service is effective, safe, and more beneficial than the available alternatives.