Friday, September 28, 2012

Hard to Swallow -- of capsules, catheters and insurance denials




None of the diagnostic tests I’ve had since my bowel resection in 2004 show any narrowing inside my small intestine, let alone an inflamed stricture where a small-bowel obstruction would likely form. Since it doesn’t make sense that the small-bowel obstructions that come on so frequently would respond to steroid therapy, resolving, as it has each time so far, after a day or two on high-dose steroids.  Dr. Cutler, my gastroenterologist, wants a capsule endoscopy test that would show 3-D, color photos taken throughout my small intestine. Here’s an illustration about capsule endoscopy from SJGI.com:

I was a bit hesitant to agree, since the last time I swallowed an endoscopy capsule, it photographed another one just hanging out in there -- one I’d swallowed two months earlier as part of a study at the University of Utah Medical Center. The result? Surgery to remove 50 cm of diseased bowel, too scarred and narrowed to let the capsules pass naturally. What if the next capsule I swallow gets trapped, too?

Now there’s a dissolving capsule the same size as the endoscopy capsule that shows up on X-rays. I could swallow that first to see if it gets stuck. An x-ray and probably physical symptoms alert if it can’t pass all the way through. The capsule dissolves 30 hours after swallowed.  It seems like a good idea to me. Even if it does cause some pain before dissolving completely, the X-ray would give long-sought information about the location and nature of the stricture. It’s not covered by insurance yet. But the University of Utah’s endoscopy department received some free samples from the manufacturer and set aside one for me.

Sounds promising, right?

But Anthem Blue Cross denied prior authorization for the procedure because:

 “You have been diagnosed with Crohn’s disease. This test is investigational and not medically necessary for testing and management of Crohn’s disease if there is a suspected or known narrowing in the small intestine (stricture) as there is in your case. Medical studies we have seen do to show that a capsule test is better than other ways of looking at the intestines for people with your condition.”

The denial letter offers multiple suggestions of other tests, most of which I’ve had, revealing no helpful information. It also says that my doctor can call a “Physician Reviewer” at Anthem UM Services, Inc. and have a peer-to-peer conversation . . . to discuss determinations based upon medical appropriateness.”

Apparently, the peer-to-peer conversation didn’t change anything. The University of Utah endoscopy lab left a voice message that because my insurance denied the request to pay for a capsule endoscopy, I would need to pay ½ the cost of the procedure up front and it would be a private-pay procedure. I called Dr. Cutler’s office and left a voice message for the medical assistant, asking if the peer-to-peer with Anthem did happen, and asking for Dr. Cutler’s suggestions, given the outcome.

When Dr. Cutler’s MA called back, she confirmed the conversation between Dr. Cutler and Anthem’s physician.  She also said Dr. Cutler would like me to have an enteroclysis. I asked her to describe the procedure. But she couldn’t explain the difference between an enteroclysis and the other tests I’ve already had. She encouraged me to set it up myself with a hospital in my insurance plan, and that if I had any questions I am welcome to make another appointment to come in and discuss it with Dr. Cutler. I asked her to spell the procedure’s name so I could research it myself.

Basically, it’s a lot like other CT and barium radiological tests, except that the doctor performing the enteroclysis inserts a tube through the patient’s nose, down the throat, past the stomach and into the small intestine. The tube infuses barium fluid, to coat the small bowel’s interior lumen, making it visible in CT images, and methylcellulose, to distend the bowel and straighten loops to improve the accuracy of the CT images, hasten the barium’s transit through the small bowel. The patient must be awake for the procedure to change positions as needed to help capture the most helpful images by CT scan. This picture of the catheter is from http://www.radiographicceu.com/article30.html.

I need to call Dr. Cutler’s office to make an appointment, but also to request a call back from the doctor himself to explain the rationale for having an enteroclysis (which we haven’t discussed before) as opposed to a double-balloon endoscopy (which he has told me may not reach the tattoo Dr. Radwin left when he approached from the bottom up), but from the top this time.

Information I looked up about the enteroclysis said the procedure is “uncomfortable.” This is code for painful and scary. I’ve put off this next phone call long enough. I’ll try in the morning.  Sigh.

Sometimes I wish I were normal – whatever that is. I do want to be as healthy as I can be. I keep praying for this and trying to at least act like Crohn’s Disease doesn’t affect every day of my life. Maybe someday that will be true.

Until next time,

Beth

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