"Information received shows you do not require this procedure [a capsule endoscopy] for the initial diagnosis of suspected Crohn's Disease when conventional diagnostic tests, including small bowel follow through or abdominal CT and a recent esophago-gastro-duodenoscopy (EGD) have shown no evidence of disease. Thus, this test is not covered under your benefit plan."Now, allow me to explain for the non-medical types why this is such a profoundly stupid statement.
Crohn's Disease is a horrible, mysterious inflammatory condition that may afflict any part of the GI tract from the mouth to the anus. It causes severe abdominal pain and diarrhea, often creating gut abscesses and boring holes that lead from the gut to the skin surface or to other organs such as the lungs. These are just a few of its tricks.
The misnamed 'small' intestine is that squiggly tube in the middle of your belly. It is about 21 feet long. It is extremely hard to detect problems there if they are more than a few inches in. This patient's gastroenterologist has done all of the standard tests one would do to look for Crohn's Disease, and they have not shown anything.
The logical next step, if you really think the patient may have the disease, is a capsule endoscopy. The patient swallows a pill that has a tiny camera. As the pill travels through gut, it snaps flash candids of the whatever or whoever is there. The patient carefully watches so she can retrieve the little traveler and send it back home once it has exited the from where the sun does not shine.
I checked Aetna's own website for the policy cited in the denial letter.
"Aetna considers capsule endoscopy medically necessary for the following indications:I showed this policy to my eight year old son, B. B felt that Aetna would consider the capsule endoscopy medically necessary. Now, B is a good reader and smart kid, but you would think that an adult who is paid to interpret insurance policies could do at least as well as a bright third grader.
. . . 3. For initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel follow-through or abdominal CT scan/CT enterography and upper and lower endoscopy (esophago-gastro-duodenoscopy (EGD) and colonoscopy; [italics added] . . ."
Tomorrow, I'm going to check to see if the gastroenterologist has appealed this yet. Assuming he has not, and assuming I can navigate the phone labyrinth (which is a big assumption), I'm going to town on these idiots tomorrow.