Diagnosis: Esophageal ulcer

Treatment is EGD (esophagogastroduodenoscopy) (procedure code 43239)

The denial is overturned EGD (procedure code 43239)

The patient has a history of an esophageal ulcer and presented with epigastric pain and reflux. An endoscopy was being done to evaluate for healing of the ulcer and the erosive esophagitis. The endoscopy reported that the patient now had non erosive esophagitis and no ulcer was found. Endoscopic biopsies found chronic gastritis without H (Helicobacter) Pylori.

MCG (Milliman Care Guidelines) guideline ACG: A-0203 lists indications for Upper GI (gastrointestinal) Endoscopy. Among the indications for the procedure is having gastroesophageal reflux disease with a history of known severe erosive esophagitis requiring follow up after treatment with a PPI (proton pump inhibitor).

This patient had severe erosive esophagitis with an esophageal ulcer in the past. She was now having epigastric pain and reflux. Doing an endoscopy to evaluate if the severe erosive esophagitis was still present met MCG criteria for the procedure.

The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary.

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