Gastroenterology Coding Alert

Question: We recently reported esophagogastroduodenoscopy (EGD)/upper endoscopy for a 13-year-old patient with abdominal pain. Aetna denied the claim saying it wasn't medically necessary. Should we appeal?

Codify Subscriber

Answer: The decision on whether or not to appeal the claim should ultimately be left to the physician, but one thing that could help her in the decision-making process is to review Aetna's policy. Its most recent upper GI coverage determination lists the circumstances under which the payer considers EGD "experimental and investigational." Among the conditions on that list are the following, among others:

• EGD for confirming placement of gastric band
• Evaluation of metastatic adenocarcinoma of unknown primary site when the results will not alter management
• Repeat EGD for persons with a prior normal EGD if symptoms remain unchanged
• Routine evaluations of abdominal pain in children (i.e. without other signs and symptoms suggestive of serious organic disease)

It's that last bullet point that most likely explains why your claim was denied. If the pediatric patient does, in fact, have other signs and symptoms suggestive of serious organic disease and the gastroenterologist has documented those in the medical record, she may choose to appeal the claim. You'll submit copies of the documen­tation with the appeal letter, which show that the patient's other signs and symptoms warranted the EGD. The gastroenterologist's letter should explain why EGD was the best choice for diagnosing the patient in light of the patient's signs and symptoms.

Resource: To read Aetna's policy, visit http://www.aetna.com/cpb/medical/data/700_799/0738.html.