Diagnosis: Abdominal pain

Treatment: Diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239

The insurer denied coverage for diagnostic EGD, procedure code 43239

The denial is upheld

The patient was presented with upper abdominal pain. There is a family history that a cousin had colon cancer and his uncle had stomach cancer. The patient underwent endoscopy and colonoscopy. Biopsies of the stomach and esophagus showed mild chronic inflammation. Helicobacter Pylori was not found.

Milliman Care Guidelines (MCG) guideline ACG: A-0203 lists indications for Upper Gastrointestinal (UGI) endoscopy. Dyspepsia is an indication if it is associated with a risk factor. These risk factors include age 60 years old, failure of medical therapy, family history of UGI cancer in a first degree relative, and persistence of pain for 3 months or longer.

The submitted documentation states that the patient was not on any medications. He did not try and fail proton pump inhibitor (PPI) therapy. The abdominal exam was benign. He had an uncle with an upper gastrointestinal (GI) malignancy but did not have a first degree relative. He did not meet MCG criteria for doing an Upper GI endoscopy.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD), procedure code 43239 is upheld. Medical Necessity is not substantiated.