Issued and entered March 29, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On February 24, 2003, XXXXXXXXXXX (Petitioner) filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901 et. seq. After a review of the material submitted, the Commissioner accepted the request. The issue involved is medical in nature. The Commissioner therefore assigned it to an independent review organization (IRO) on March 3, 2003. On March 17, 2003, the IRO provided its recommendation to the Commissioner.

II
FACTUAL BACKGROUND

On XXXXXXXXXXX, Petitioner had an initial office visit for a possible colonoscopy at XXXXXXXXXXXXXXXXXXXXXXXX. (XXXXXXXXXXXXX). The doctor charged $77.00. On XXXXXXXXX, she had a colonoscopy at XXXXXXXXXXXXXX. XXXXXXXXXXXX billed $803.00 and XXXXXXXXXXXXXX charged $763.50. BCBSM denied payment for all charges claiming they were billed as a “screening diagnosis.”

Petitioner claims that she has a family history of colorectal cancer and therefore her colonoscopy is not a screening procedure and therefore a covered benefit under her Certificate with BCBSM.

III
ISSUE

Is BCBSM required to pay for the XXXXXXXXXXXX, colonoscopy and related services?

IV
ANALYSIS

Petitioner’s Argument

BCBSM paid for an ultrasound performed prior to her colonoscopy. This was necessary because Petitioner had a family history of aneurysms. She also had a family history of colon cancer; two of her uncles died of this disease. Petitioner argues that her colonoscopy was not for “screening purposes,” but was medically necessary and was a covered benefit. BCBSM should pay the full cost of these services.

BCBSM’s Argument

Petitioner has health coverage under the BCBSM Community Blue Group Benefit Certificate.

The Certificate provides coverage for medically necessary services that are directly related to the diagnosis and management of the patient’s condition. It does not cover screening, which by definition, is not directly related to the diagnosis or treatment of a disease.

BCBSM’s medical consultants reviewed the Petitioner’s medical records. The consultant found the Petitioner’s colonoscopy was a screening procedure as noted in the Operative/Procedure Report of XXXXXXXXXX. The records indicate no history of colorectal cancer in the Petitioner’s family. In addition, she did not complain of any change in her bowel habits and had no rectal bleeding. There was nothing in the medical records documenting colon cancer or any increased risk for it.

The only instances where the Certificate covers screening services are screening mammography and those shown under Preventative Care Services. These include fecal occult blood screening and prostate specific antigen screening. Thus, screening colonoscopies are not part of the Petitioner’s Preventative Care Services.

Independent Review Organization (IRO) Recommendation

The IRO concluded that the Petitioner is completely asymptomatic without any gastrointestinal symptoms and without any increased risk of colon cancer. A flexible sigmoidoscopy is a covered benefit under the provisions of the Certificate as a screening procedure. Therefore, the IRO recommended upholding BCBSM’s denial of coverage of Petitioner’s colonoscopy.

Commissioner’s Review

The Certificate of Coverage controls the analysis of this matter. It defines Screening Services as:

Procedures or tests ordered for a patient (or for almost all patients of a particular class or group) that are not directly related to a diagnosis or treatment of a specific disease or injury. For example, tests routinely performed as a part of a physical are considered screening.

The Certificate covers screening mammography. It also covers certain screening procedures as part of preventative care services. These services include flexible sigmoidoscopy examination and fecal occult blood screening that are used to detect colon cancer. The Certificate however does not include coverage for a colonoscopy for screening purposes.

The IRO found the Petitioner asymptomatic for gastrointestinal problems and concluded she is not at an increased risk for colorectal cancer. The Commissioner agrees with this conclusion and finds the Petitioner’s colonoscopy was a screening procedure and not a covered benefit under the BCBSM Certificate.

V
ORDER

The Commissioner upholds the BCBSM final adverse determination in this matter. BCBSM is not required to pay for the colonoscopy and related services. This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.