Gastroenterology Coding Alert

Question: We recently reported esophagogastroduodenoscopy (EGD)/ upper endoscopy for a 17-year-old patient with abdominal pain. Aetna denied the claim saying it wasn’t medically necessary. Should we appeal?

Florida 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 them in the decision-making process is to review Aetna’s policy. Its most recent upper GI coverage determination, which was last updated in July 2021, Aetna 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, they 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. Sometimes the claim can just be resubmitted with more specific and severe diagnoses (e.g. vomiting, bleeding, weight loss) rather than a more general abdominal pain diagnosis and the claim might be paid on reconsideration.

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