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202109-141883

2021

United Healthcare Ins. Co. of NY

Indemnity

Digestive System/ Gastrointestinal

Diagnostic Testing (other than Radiology)

Experimental/Investigational

Overturned

Case Summary

Diagnosis: Irritable Bowel Syndrome (IBS).
Treatment: Current procedural terminology (CPT) code 83993, calprotectin, fecal testing.

The insurer denied coverage for current procedural terminology (CPT) code 83993, calprotectin, fecal testing.

The denial is overturned.

The patient has a history of inflammatory bowel disease/syndrome (IBD/S). It is reported that she has been having persistent bloating, gas pains, and diarrhea. A stool for fecal calprotectin was ordered.

Up To Date has an article titled "Approach to the adult with chronic diarrhea in resource-rich settings." Fecal calprotectin is discussed in the section on general laboratory tests. The article states that fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from non-inflammatory causes of chronic diarrhea. If fecal calprotectin levels are normal a diagnosis of IBD is unlikely.

An article has been provided for review titled "Calprotectin in Daily Practice: Where do we Stand." (Digestion 2017;95:293-301). The conclusion was that fecal calprotectin is a reliable marker of intestinal inflammation with good clinical sensitivity. It is useful in the differential diagnosis between Inflammatory Bowel Disease and Irritable Bowel Syndrome.

The scientific literature supports the use of fecal calprotectin as leading to better health outcomes. The FDA [Food and Drug Administration] has cleared calprotectin as a marker intended for differentiating Irritable Bowel Syndrome from IBD. Since the patient has a diagnosis of IBS and is having chronic diarrhea she is a good candidate for the test. It is one of several tests that can help differentiate IBS from IBD. There are no adverse risks from obtaining this test. The use of fecal calprotectin has been shown to be beneficial for patients with Irritable to rule out Inflammatory Bowel Disease.

The carrier's denial of current procedural terminology (CPT) code 83993, calprotectin, fecal testing performed should be overturned. It is more beneficial than any other standard treatments.

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