Diagnosis: Gastroesophageal reflux disease.
Treatment: Esophagogastroduodenoscopy.

The insurer denied the Esophagogastroduodenoscopy. The determination is upheld.

This is a patient with gastroesophageal reflux disease (GERD). He had persistent gastroesophageal reflux disease symptoms despite omeprazole 20 milligrams (mg) daily. He presented with anemia and heartburn; he had been noted to have a low hemoglobin and normal iron level, followed by a normal hemoglobin level on reassessment. He presented on omeprazole and Pylera for the treatment of a Helicobacter pylori infection, with increased reflux. At issue is the medical necessity of an esophagogastroduodenoscopy.

The medical necessity of an esophagogastroduodenoscopy is not supported by the provided documentation. Per the most recent American Society for Gastrointestinal Endoscopy guidelines for appropriate use of endoscopy, colonoscopy is recommended for evaluation of iron deficiency anemia [1]. Esophagogastroduodenoscopy (EGD) is recommended for evaluation of anemia only if a colonoscopy does not reveal a cause [1]. Additionally, the patient did not have documented persistent anemia, or documented iron deficiency.

Clinical guidelines recommend endoscopy for investigation of upper gastrointestinal symptoms (such as gastroesophageal reflux disease) when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response [2]. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful [1]. The most recent American College of Physicians guidelines for use of upper endoscopy in gastroesophageal reflux disease state that upper endoscopy is indicated in men and women with heartburn and alarm symptoms, such as bleeding [2]. The most recent American College of Gastroenterology guidelines for investigation of dyspepsia state that EGD is warranted if symptoms have been refractory to proton pump inhibitor for 4-8 weeks [3]. In this case, documentation that symptoms were refractory to continuous proton pump inhibitor for at least 4 weeks, as recommended by the most recent American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD), is lacking [4]. Other indications for endoscopy, such as melena, were also not documented. These statements are concordant with more recent guidelines and literature [5-7].