Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: procedure code 43239, esophagogastroduodenoscopy (EGD)

The insurer denied coverage for procedure code 43239, EGD

The denial is overturned

The patient has a history of chronic esophageal reflux disease. He was not on recent anti-reflux medications. He had a history of having an esophageal ulcer. He also had not had a colonoscopy in over a decade. An endoscopy revealed an esophageal ulcer and gastritis. The biopsy showed an ulcer and active esophagitis. At the gastroesophageal (GE) junction there was a Hill 2 GE flap.

Milliman care Guideline (MCG) ACG: A-0203 lists indications for Upper Gastrointestinal (GI) Endoscopy. A male who has had GERD for 5 years with a hiatal hernia is an indication for the procedure. Severe erosive esophagitis after proton pump inhibitor (PPI) treatment is also an indication to do an endoscopy.

This patient has chronic GERD and a history of severe esophagitis with an esophageal ulcer. The GE junction finding with an abnormal Hill Classification is part of a hiatal hernia evaluation and is associated with reflux. In addition, the patient has known severe esophagitis and never had a follow up endoscopy. In view of his age, the history of an esophageal ulcer, and the abnormal Hill classification it was appropriate to do an endoscopy. The health care plan did not act with sound medical judgment or in the best interest of the patient. Doing an upper GI endoscopy was medically necessary.

The insurer's denial of coverage for procedure code 43239, esophagogastroduodenoscopy (EGD) is overturned. Medical Necessity is substantiated.