Why My Prescription was Denied

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Some time ago, I performed an upper endoscopy, or EGD, on a patient who had a family history of Barrett’s esophagus (BE).  In this condition, the esophagus has developed a new internal lining which is readily apparent when examined with a scope.  These patients are followed periodically because of an increased risk of developing cancer, which fortunately is a rare event in this condition. 

I discovered reflux esophagitis at the lower portion of her esophagus. Curiously, she had no heartburn or other symptoms of reflux.  I did not identify BE and the biopsy results were benign.  One of the mysteries of gastroenterology is that at times we discover fairly intense acid damage to the esophagus in a patient who is experiencing no symptoms.  And it is quite common that patients suffering from horrendous heartburn have normal scope results.  Ah, the mysteries of the human body...

Despite her absence of symptoms, I prescribed a standard reflux medicine which should have a very high probability of healing the injury.   I recommended that she return for an EGD in 3 months to verify that she was healed.

Perhaps, on a future post I can discuss the phenomenon of patients who are advised orally and in writing to follow up after a specified interval, but fail to do so.  It was well beyond a year when this patient returned for her ‘3-month scope recheck’.

Surprisingly, the repeat EGD showed that her esophagitis had worsened despite the reflux medicine that she had been faithfully taking.  Fortunately, biopsy results were again all benign. I had been extremely confident that the recheck EGD would verify healing.  Confidence, however, is not data.

So, we have now reached the point of this post.  I advised this patient to double her reflux medicine and to return for a 3rd EGD in 3 months’ time.  (I think she’ll show up this time.)  You don’t have to be a digestive medical specialist to understand the rationale of my dosing increase recommendation. It’s called common sense.

• Reflux esophagitis initially found.
• Standard reflux medication prescribed
• Worse esophagitis seen on repeat EGD
• Dose of reflux medication increased.

Prescription denied!

On the very day I prescribed the increased dosage of her reflux medication, we received a denial because the dosing increase was not 'standard'.  Welcome to the Medical Theater of the Absurd!  While the dose was not standard, there was sound medical judgment underlying this recommendation.  Hopefully, we will ultimately get it approved after jumping through the requisite hoops and submitting fun paperwork.  All of this burns up time and is fuel for patient frustration and professional burn out..  Even a cursory review of the medical record would validate the medication change.

Imagine how much time is incinerated in physicians’ offices battling insurance companies over legitimate diagnostic testing and treatment advice?  Does this represent best practices in the medical profession?  I recognize that insurance companies are entitled to know that the care that they pay for is legitimate.  But the net that they wield in this process is much too large.  They should use a scalpel, not an axe.