Diagnosis: Diarrhea.
Treatment: Colonoscopy (45380) performed in a hospital (or hospital clinic).
The insurer denied the Colonoscopy (45380) performed in a hospital (or hospital clinic).
The denial is upheld.

The patient is a male patient who underwent a colonoscopy. The patient had undergone a colonoscopy for colon cancer screening and change of bowel habits at a gastrointestinal (GI) endoscopy and surgery center.

No, the proposed treatment, colonoscopy (45380) performed in a hospital (or hospital clinic) was not medically necessary.
The colonoscopy as performed was medically indicated for the evaluation of chronic diarrhea. The setting at which the care was provided was not medically necessary. There was no cogent medical information provided to support the performance of this service at an on-campus hospital setting. The patient did not have significant medical conditions, an American Society of Anesthesiologists (ASA) class of III, or other conditions such as morbid obesity or severe obstructive sleep apnea (OSA) requiring care at an on-campus service site.

The plan declined the request as follows:
"This service can be approved under the plan clinical criteria in a hospital setting when one of these is met: 1) there are no other places nearby to obtain the service; or 2) the medical status or the procedure needs monitoring that can only be done in a hospital; and if problems occur, the person can only be treated safely in a hospital. The information we have does not show you have any of these problems. For this reason, this request for the procedure to be done in a hospital (or hospital clinic) is denied as not medically necessary."

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The colonoscopy as performed was medically indicated for the evaluation of chronic diarrhea. The setting at which the care was provided was not medically necessary. There was no cogent medical information provided to support the performance of this service at an on-campus hospital setting. The patient did not have significant medical conditions, an American Society of Anesthesiologists (ASA) class of III, or other conditions such as morbid obesity or severe obstructive sleep apnea requiring care at an on-campus service site.