Diagnosis: Digestive System/Gastrointestinal
Treatment: Surgical Services
The health plan denied the procedure of Endoscopy as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient is under evaluation for dyspeptic symptoms including upper abdominal discomfort and bloating. The patient had a gastrointestinal (GI) series that was unremarkable. One office note and the upper endoscopy procedure is included for review. The provider performed an upper endoscopy for the indication of dyspepsia.

The Endoscopy was not medically necessary for this patient. Per the American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) Clinical Guidelines [1] endoscopic evaluation of patients less than 60 years should be reserved for patients with any one of the following:
- Clinically significant weight loss (greater than 5 percent usual body weight over
6 to 12 months).
- Overt gastrointestinal bleeding.
- greater than 1 other alarm feature*
- Rapidly progressive alarm features.
*Alarm features include:
- Unintentional weight loss
- Dysphagia
- Odynophagia
- Unexplained iron deficiency anemia
- Persistent vomiting
- Palpable mass or lymphadenopathy
- Family history of upper gastrointestinal cancer
Based on the information provided the patient has no alarm features. The recommended treatment would be to empirically test and treat for H pylori. Patients who are H. pylori negative or who continue to have symptoms after successful eradication of H. pylori should be treated with antisecretory therapy with a proton pump inhibitor. The standard of care is to empirically test and treat for H pylori. Upper endoscopy is generally not indicated because of the very low yield of finding significant pathology.