Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Constipation. 
Treatment: Colonic Manometry. 
The insurer denied the Colonic Manometry. 

The determination is overturned. 

The patient has a history of chronic constipation, refractory to medical therapy. She has tried and failed numerous treatments and dietary intervention. At issue is the medical necessity of colonic manometry studies. 

The colonic manometry is medically necessary. Colonic manometry studies can provide valuable information that can influence medical and possibly surgical therapy. Colonic motility studies are widely used and are adopted by the major academic pediatric centers and are currently a standard procedure in evaluating refractory constipation. There is adequate scientific evidence supporting the use of these studies. This is a patient with chronic constipation who has failed numerous treatments. 
Per Rodriguez, L., et al. "An ANMSNASPGHAN consensus document on anorectal and colonic manometry in children." Neurogastroenterology & Motility 29.1 (2017): "Anorectal and colonic manometry are now commonly used in all major pediatric referral centers as diagnostic tools and to guide the management of children with intractable constipation and fecal incontinence, particularly when a surgical intervention is being considered. Purpose: This review highlights some of the recent advances in pediatric colon and anorectal motility testing including indications and preparation for the studies, and how to perform and interpret the tests. This update has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)." (1) 
Per Yacob, Desale, and Carlo Di Lorenzo. "Colonic Manometry." Pediatric Neurogastroenterology (2017). "Homeostasis of the gastrointestinal tract is maintained and coordinated by complex mechanisms involving its nervous system and musculature. These processes allow the colon to generate specific motility patterns, enabling it to accomplish its function of reabsorbing fluids and electrolytes, propelling waste distally, and preparing for its elimination. Much information has become available in the past decade on the motility of the colon in children and adults. In children and adolescents with severe defecatory disorders, evaluation of the colonic motor function is now routinely being utilized to direct medical and surgical treatment." (2)
Colonic manometry has been shown to be helpful in discriminating between functional disorders and neuromuscular diseases in children with severe constipation unresponsive to standard medical treatment. (4)
In a retrospective study on the impact of colonic manometry in children, with constipation, treatment modifications were made in 93% patients based on colonic manometry, with suggestion for surgical intervention in 68%. In a follow-up of these patients, caretakers reported that the symptoms that had prompted the colonic manometry evaluation were improved in 78% and 88% of parents believed suggestions given after colonic manometry had been helpful and led to improvement in their children's health. (5) 
On the basis of the extent of colonic neuromuscular dysfunction identified on colonic manometry, optimal surgical intervention could be determined such as an ileostomy, in case of colonic involvement; cecostomy in case of limited involvement of the distal colon; appendicostomy in case of rectosigmoid dilation; partial colectomy, in case of segmental colonic dysmotility. (6) 
On the current standard of care and scientific evidence, the requested motility studies are appropriate and medically necessary for this patient with chronic refractory constipation.