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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the fecal calprotectin testing for evaluation of the enrollees possible inflammatory bowel disease. Findings:  The 3 physician reviewers found that the use of fecal calprotectin testing to diagnose change in bowel habits has not been accepted for routine use in this clinical setting. According to the American College of Physicians (ACP) a specialist might measure fecal calprotectin, but only in conjunction with detailed history-taking, clinical examination, and serum inflammatory markers or other blood tests, to determine the need for endoscopic evaluation. The ACP also stated that fecal calprotectin is elevated in several other gastrointestinal diseases, including viral, bacterial, and protozoal causes of infective diarrhea. The impact of this laboratory test on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation. A recent meta-analysis of inflammatory bowel disease markers reported that the relatively poor specificity of fecal calprotectin in Crohns disease is a concern, as a false positive test could lead to treatment of a patient without endoscopically active disease.  For these reasons, the fecal calprotectin testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the testing 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.  Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.