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Diagnosis: Postherpetic neuralgia.
Treatment: Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).
The insurer denied the Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).
The patient is a male with post-herpetic neuralgia with significant intensity that has failed an adequate trial of nonsurgical management. The patient was recommended peripheral nerve stimulation of V1 (ophthalmic nerve) and V2 (maxillary nerve).
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Overturned
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Experimental/Investigational
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Diagnosis: Postherpetic neuralgia.
Treatment: Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).
The insurer denied the Outpatient Procedure 76000x 1, 64555 x 1, 95972 x 1 (occipital nerve stimulation).
The denial is overturned.
The patient is a male with post-herpetic neuralgia with significant intensity that has failed an adequate trial of nonsurgical management. The patient was recommended peripheral nerve stimulation of V1 (ophthalmic nerve) and V2 (maxillary nerve).
Yes, the health plan should cover the requeted health service.
On evaluation of the literature, there are multiple studies examining outcomes associated with this type of treatment.
"This study revealed that PNS [peripheral nerve stimulation] is an effective treatment for trigeminal herpetic neuralgia following acute or subacute HZ [Herpes Zoster]. As a extend neuromodulation method, subcutaneous peripheral nerve-field stimulation might be a useful option to reduce the progression of neuropathic changes caused by persistent transmission of pain signals in the trigeminal nerve branches after the acute or subacute phase of HZ [Herpes Zoster]." (2)
"SON [supraorbital nerve] and/or ION [infraorbital nerve] stimulation can be an effective treatment for intractable facial pain due to post-herpetic, traumatic or idiopathic etiology." (1)
Yes, the requested health service is more beneficial.
Yes, there are limited alternatives for this patient, and all are not very effective.
| 1 |
Diagnosis: Recurrent venous thromboembolism.
Treatment: Eliquis.
The insurer denied the Eliquis.
The patient has a history of recurrent venous thromboembolism. The patient is currently on apixaban and is tolerating it well but it is not a formulary option. She has not failed other anticoagulants.
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Upheld
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Formulary Exception
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Diagnosis: Recurrent venous thromboembolism.
Treatment: Eliquis.
The insurer denied the Eliquis.
The determination is upheld.
The patient has a history of recurrent venous thromboembolism. The patient is currently on apixaban and is tolerating it well but it is not a formulary option. She has not failed other anticoagulants. Rivaroxaban (Xarelto) is a formulary option. Apixaban (Eliquis) is under review.
Neither Xarelto nor Warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that the patient failed them; similarly, there is a paucity of documentation indicating that this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus, given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
| 1 |
Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visits (x12).
The insurer denied coverage for D8080 braces and D8670 monthly visits (x12).
.
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.
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Upheld
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Medical necessity
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Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visits (x12).
The insurer denied coverage for D8080 braces and D8670 monthly visits (x12).
The denial is upheld.
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.
Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.
In this case, the treating orthodontist claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies as referenced below.
Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.
The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.
D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.
The insurer's denial of coverage for D8080 braces and D8670 monthly visits (x12) is upheld. Medical Necessity is not substantiated.
| 1 |
Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
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Upheld
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Medical necessity
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Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.
The patient has a history asthma, gastroesophageal reflux disease (GERD), and Methadone Dependence. They presented to the emergency department (ED) with complaints of shortness of breath (SOB) and some productive cough with whitish sputum. The patient was noted to be using some accessory muscles. The patient was awake and alert. As per the physical exam the patient was in no acute distress. There was some decreased air entry noted along with wheezing and positive rales. Laboratory studies revealed the white blood count was 9.7 the hemoglobin was 8.4 and the hematocrit was 28. Electrolytes were within normal limits. A chest X ray revealed no signs of pneumonia. Have the patient had a peak expiratory flow (PEF) which was reported to be 100. The patient was treated with intravenous (IV) steroids, bronchodilators (BD), Magnesium and antibiotics.
As per the history and physical the patient was in no acute distress with expiratory wheezing noted. As per the note, the patient was awake and alert heart rate was 84, blood pressure was 138/60, respiratory rate was twenty, oxygen saturation was 97% (percent) on room air and arterial blood gases were 7.38/47/94/28%.
The patient was continued on treatment with steroids bronchodilators and antibiotics the patient remained stable after admission the patient signs out against medical advice a few hours later.
This patient was in the hospital for under 24 hrs. This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Patient could be in Observation status for up to 48 hours.
This patient remained stable after admission. The patient was not hypoxic. Oxygen saturation was 97% on room air. There were no signs of pneumonia on chest X ray.
This patient was stable to have been discharged home after a period under observation. they could have been discharged on oral steroids bronchodilators and oral antibiotics if clinically needed.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
| 1 |
Diagnosis: Bronchiolitis.
Treatment: Full hospital admission.
The insurer denied coverage for full hospital admission.
This is a patient who had been sick for 3 days with a cough, congestion, and a runny nose. His mother brought him to the pediatrician, who noted wheezing and increased work of breathing and arranged for the child to be transported to the Emergency Room (ER).
In the ER he was irritable, crying and appeared fatigued. He was noted to have persistent respiratory distress with tachypnea with increased work of breathing. He was initially treated with Decadron and nebulized albuterol with little improvement noted. He then received treatment with duoneb, a dose of racemic epinephrine and intravenous (IV) fluids. He tested positive for the metapneumovirus. When he continued to have an elevated respiratory rate of 40, wheezing, rhonchi and diffuse crackles upon auscultation of the lung, the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis for continued treatment with oxygen and albuterol every 3 hours.
Patient was treated appropriately in the ER for respiratory distress with hypoxemia related to a
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Overturned
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Medical necessity
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Diagnosis: Bronchiolitis.
Treatment: Full hospital admission.
The insurer denied coverage for full hospital admission. The denial is overturned.
This is a patient who had been sick for 3 days with a cough, congestion, and a runny nose. His mother brought him to the pediatrician, who noted wheezing and increased work of breathing and arranged for the child to be transported to the Emergency Room (ER).
In the ER he was irritable, crying and appeared fatigued. He was noted to have persistent respiratory distress with tachypnea with increased work of breathing. He was initially treated with Decadron and nebulized albuterol with little improvement noted. He then received treatment with duoneb, a dose of racemic epinephrine and intravenous (IV) fluids. He tested positive for the metapneumovirus. When he continued to have an elevated respiratory rate of 40, wheezing, rhonchi and diffuse crackles upon auscultation of the lung, the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis for continued treatment with oxygen and albuterol every 3 hours.
Patient was treated appropriately in the ER for respiratory distress with hypoxemia related to a metapneumovirus infection. The presence of persistent respiratory distress and chest congestion with wheezing and rales are all signs of significant respiratory distress, and in view of the ongoing need for oxygen therapy the decision to admit for continued oxygen supplementation was consistent with the standard of care for a young child with bronchiolitis and hypoxemia. The decision to admit to the hospital for ongoing treatment with oxygen was appropriate and consistent with the standard of care.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for full hospital admission is overturned. Medical Necessity is substantiated.
| 1 |
Diagnosis: Breast Cancer
Treatment: AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
The insurer denied AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
This is a patient with estrogen receptor positive (+) metastatic breast cancer. The disease was previously human epidermal growth factor receptor 2 (HER2)+ but is now HER2 negative (-). She has had multiple lines of therapy including TCH [Taxotere or Taxol, carboplatin and Herceptin], Zoladex plus (+) an aromatase inhibitor (AI)+everolimus, Faslodex+Ibrance, Kadcyla, Xeloda, carboplatin, eribulin, CMF [cyclophosphamide, methotrexate, fluorouracil], paclitaxel, Trodelvy, and gemcitabine.
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Upheld
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Medical necessity
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Diagnosis: Breast Cancer
Treatment: AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
The insurer denied AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
The determination is upheld.
This is a patient with estrogen receptor positive (+) metastatic breast cancer. The disease was previously human epidermal growth factor receptor 2 (HER2)+ but is now HER2 negative (-). She has had multiple lines of therapy including TCH [Taxotere or Taxol, carboplatin and Herceptin], Zoladex plus (+) an aromatase inhibitor (AI)+everolimus, Faslodex+Ibrance, Kadcyla, Xeloda, carboplatin, eribulin, CMF [cyclophosphamide, methotrexate, fluorouracil], paclitaxel, Trodelvy, and gemcitabine. Due to a rising tumor marker (with stable radiographic disease), cyclophosphamide+5- fluorouracil (FU) +carboplatin+irinotecan+bevacizumab was started. AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer] was denied by the health plan and is under review for medical necessity.
No. In patients with metastatic HER2- breast cancer, there is a paucity of evidence that combination chemotherapy improves outcomes. Neither the National Comprehensive Cancer Network (NCCN), nor the authors of UpToDate, nor the peer-reviewed literature recommend this approach. Further, some of the drugs in this regimen have previously been administered with progression. Evidence is lacking that repeat exposure in a different combination re-establishes drug sensitivity; it is only clear that it increases toxicity, which has been experienced (treatment-limiting cytopenias).
For these reasons, medical necessity cannot be established for this combination in this clinical scenario.
| 1 |
Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
This patient presented to the hospital complaining of chest pain. He noted that his pain was so severe that he wanted to jump out of a window. There were no associated symptoms accompanying his chest pain. Past medical history was relevant for coronary artery disease, a LAD (left anterior descending) stent, hypertension, atrial fibrillation, EtOH (ethanol alcohol) abuse and seizures. Upon arrival his vital signs were stable (pulse 94bpm (beats per minute), BP (blood pressure) was 130/87mmHg (millimeters of mercury). His physical exam was significant for chest tenderness with palpation of sternum. Serum blood testing demonstrated no elevation in high sensitivity troponin (peak 4.3ng (nanograms)/L (liters), normal range 0-35) an ECG (electrocardiogram) demonstrated normal sinus rhythm with premature atrial beats and no ST (interval on a (electrocardiogram) or T wave (interval on a (electrocardiogram) abnormalities. The patient was admitted to the hospital for monitoring and treatment. Acute coronary syndrome was ruled out and the patient was discharged on medical therapy.
This patient presented with atypical chest pain and no significant past medical history. Her pretest
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Upheld
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Medical necessity
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Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld.
This patient presented to the hospital complaining of chest pain. He noted that his pain was so severe that he wanted to jump out of a window. There were no associated symptoms accompanying his chest pain. Past medical history was relevant for coronary artery disease, a LAD (left anterior descending) stent, hypertension, atrial fibrillation, EtOH (ethanol alcohol) abuse and seizures. Upon arrival his vital signs were stable (pulse 94bpm (beats per minute), BP (blood pressure) was 130/87mmHg (millimeters of mercury). His physical exam was significant for chest tenderness with palpation of sternum. Serum blood testing demonstrated no elevation in high sensitivity troponin (peak 4.3ng (nanograms)/L (liters), normal range 0-35) an ECG (electrocardiogram) demonstrated normal sinus rhythm with premature atrial beats and no ST (interval on a (electrocardiogram) or T wave (interval on a (electrocardiogram) abnormalities. The patient was admitted to the hospital for monitoring and treatment. Acute coronary syndrome was ruled out and the patient was discharged on medical therapy.
This patient presented with atypical chest pain and no significant past medical history. Her pretest probability of coronary artery disease is high. (Reference 1) Utilizing the HEART (history, ecg, age, risk factors, troponin) score he was considered low risk. (Reference 2) Utilizing the TIMI (thrombolysis in myocardial infarction) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST (interval on an electrocardiogram) changes on an ECG was reviewed by Hedayati et al. (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
| 1 |
Diagnosis: Cholelithiasis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The patient is a female. She presented with itching.
There was no abdominal pain, nausea, vomiting or fever. She was hemodynamically stable and noted to be jaundiced. Labs revealed elevated liver enzymes. US (ultrasound) revealed gallstones but no evidence of cholecystitis. MRCP (Magnetic Resonance Cholangiopancreatogram) revealed a normal common bile duct. She tolerated a diet.
The patient underwent liver biopsy in IR (interventional radiology), and was discharged.
.
The patient presented with painless jaundice. While she had gallstones, there was no evidence of biliary obstruction or acute cholecystitis or cholangitis.
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Upheld
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Medical necessity
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Diagnosis: Cholelithiasis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The denial is upheld.
The patient is a female. She presented with itching.
There was no abdominal pain, nausea, vomiting or fever. She was hemodynamically stable and noted to be jaundiced. Labs revealed elevated liver enzymes. US (ultrasound) revealed gallstones but no evidence of cholecystitis. MRCP (Magnetic Resonance Cholangiopancreatogram) revealed a normal common bile duct. She tolerated a diet.
The patient underwent liver biopsy in IR (interventional radiology), and was discharged.
No, the Inpatient admission was not medically necessary.
The patient presented with painless jaundice. While she had gallstones, there was no evidence of biliary obstruction or acute cholecystitis or cholangitis. The most likely etiology for her jaundice and abnormal LFTs (liver function tests) was a hepatitis, either viral or autoimmune. As she was hemodynamically stable, tolerating a diet, was not vomiting, had no fever, sepsis or obstruction, acute inpatient hospital stay was not medically necessary. A lower level of care was appropriate, and she was medically stable for discharge on day two, for an outpatient liver biopsy. Acute inpatient hospital stay was not medically necessary.
Yes, as acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
| 1 |
Diagnosis: Substance abuse
Treatment: Inpatient Rehabilitation Admission
The insurer denied the Inpatient Rehabilitation Admission
The patient is a male, unemployed, living with his girlfriend, who presented for inpatient substance-abuse rehab admission with the primary diagnoses of amphetamine/stimulant use severe, cannabis use, moderate and tobacco use, moderate. The patient presented to the hospital with the chief complaints of I don't know how to deal with my emotions. The patient states that he went on a bad binge that even his mother did not want him in her house.
The patient reports using one to three grams of crystal meth daily by injection. The patient reports daily cannabis use, smoking two joints daily with the last use on day of admission. He has had one treatment episode in the past which is described as several years ago. The patient reports inability to stop substance use on his own. He reports not having used in the last several days as family had locked him up to prevent use. No withdrawal symptoms are noted.
The patient's past withdrawal symptoms include agitation and lethargy.
Medically, the patient has a history of hypertension and asthma. He denied any mental health issues. Blood pressure was elevated on admission. Urine drug screen (UDS) was positive for cannabis. Mental status exam, mood and affect were
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Upheld
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Medical necessity
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Diagnosis: Substance abuse
Treatment: Inpatient Rehabilitation Admission
The insurer denied the Inpatient Rehabilitation Admission
The denial is upheld
The patient is a male, unemployed, living with his girlfriend, who presented for inpatient substance-abuse rehab admission with the primary diagnoses of amphetamine/stimulant use severe, cannabis use, moderate and tobacco use, moderate. The patient presented to the hospital with the chief complaints of I don't know how to deal with my emotions. The patient states that he went on a bad binge that even his mother did not want him in her house.
The patient reports using one to three grams of crystal meth daily by injection. The patient reports daily cannabis use, smoking two joints daily with the last use on day of admission. He has had one treatment episode in the past which is described as several years ago. The patient reports inability to stop substance use on his own. He reports not having used in the last several days as family had locked him up to prevent use. No withdrawal symptoms are noted. No Clinical Opiate Withdrawal Scale (COWS) scores or Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores are provided for review. No current withdrawal symptoms are noted. The patient's past withdrawal symptoms include agitation and lethargy.
Medically, the patient has a history of hypertension and asthma. He denied any mental health issues. Blood pressure was elevated on admission. Urine drug screen (UDS) was positive for cannabis. Mental status exam, mood and affect were appropriate. No hallucinations, suicidal ideations or homicidal ideations are noted. There was no history of self injurious behavior.
No, the proposed inpatient rehabilitation admission was not medically necessary. On presentation, the patient did not present with acute or life-threatening withdrawal symptoms. On presentation, the patient did not have any withdrawal symptoms. His mood and affect were appropriate. He did not have any psychotic symptoms. He did not have any suicidal or homicidal ideation. His vital signs showed elevated blood pressure but the patient was noted to have a history of hypertension.
Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient did not present with acute withdrawal or life-threatening withdrawal symptoms or a history of complicated withdrawal symptoms or multiple past treatment failures to warrant inpatient rehabilitation.
| 1 |
Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient Hospital Stay.
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Upheld
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Medical necessity
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Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient Hospital Stay.
The determination is upheld.
The patient presented to the emergency department (ED) with chest pain and lightheadedness. The patient reported symptoms for 2 days in a row. The chest pain, described as tightness, lasted for 3 hours. It started at rest. The patient reported no previous cardiac history. The tightness improved with walking and sleeping.
The patient has a history of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, chronic back pain and hypothyroidism. The patient has a history of tobacco abuse and quit 2 years ago. He recently noted constipation.
His vital signs in the emergency department (ED) were as a blood pressure (BP) of 146/84, pulse 74 beats per minute (BPM), temperature 98.5 degrees Fahrenheit, oxygen saturation (O2 sat) 94%. His physical examination was unremarkable. His lab results were unremarkable.
His troponin was normal. His creatine kinase (CK), total was elevated; it peaked at 526. A D -dimer was normal. His thyroid stimulating hormone (TSH) was 31. His electrocardiogram (ECG) revealed sinus rhythm without acute ST or T changes. There was a non-specific intraventricular conduction delay. His chest x-ray (CXR) was normal. The patient was admitted to the hospital. Based on an elevated total CK, he was diagnosed with non ST-Elevation Myocardial Infarction (STEMI). The patient was started on intravenous (IV) Heparin. The patient underwent an echocardiogram and it revealed an ejection fraction (EF) of 55% with severe inferolateral wall hypokinesis. The next day after the admission, the patient felt fine, without any chest pain. His serial troponin was normal. The IV Heparin was completed.
The patient was scheduled for a cardiac catheterization, which later was rescheduled. His coronary angiography revealed mid left anterior descending (LAD) 80% stenosis in the proximal segment, 90% stenosis in the mid-segment, 80% stenosis in the distal segment. His left circumflex (LCx) and right coronary artery (RCA) were patent. The patient underwent coronary intervention with 2 drug eluding stents placed in the mid LAD.
The patient tolerated the procedure well. Post procedure the patient was complaining of dyspnea and lightheadedness, similar to prior to admission. He was consulted by an endocrinologist who agreed with an increased dose of thyroid replacement.
The patient was discharged home. An inpatient stay was denied and is under review for medical necessity.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
The patient presented with atypical chest pain. He had several coronary risk factors (HTN, smoking, hyperlipidemia [HLD] and DM). Therefore, it would be appropriate to observe the patient in the hospital on telemetry unit with serial electrocardiograms (ECG) and cardiac enzymes. However, this could have been done at a lower level of care. The patient ruled out for a myocardial infarction (MI) with serial normal troponins. His ECG did not reveal any ischemic changes. His vital signs were stable. His chest pain resolved. His CXR and lab results were normal. The appropriate management would be to observe for 24 hours and discharge home after serial troponin was normal. However, the patient was diagnosed with non ST-Elevation Myocardial Infarction (NSTEMI) based on an elevated CK. CK (creatine kinase) has at least 3 fractions-creatine kinase myocardial band (CK-MB) [found mostly in the heart muscle], creatine kinase muscle (CK-MM) [found mostly in skeletal muscles] and creatine kinase brain (CK-BB) [found mostly in brain tissue]. Only CK-MB is released from the myocardium. Myocardial damage is demonstrated by measuring a CK-MB index. CK-MB index was not measured. Total CK elevation never was or is used to diagnose myocardial damage. The troponin is much more sensitive and specific. In the presence of a negative troponin in series times 3, myocardial damage (myocardial infarction) should have been ruled out and the CK should have been disregarded. Therefore, the patient did not suffer a NSTEMI. The patient did not have indications for a prolonged hospital stay. He did not have indications for a coronary angiogram and coronary intervention as an inpatient. His coronary artery disease, in LAD territory, was an incidental finding.
In addition, his echocardiogram revealed inferolateral hypokinesis. That implied that the patient had ischemia in RCA or Cx territory, which supplies the inferolateral wall. But his RCA and Cx were patent. However, disease was found in LAD territory, which supplied the anterior wall. Anterior wall was not hypokinetic. In summary, the patient did not have indications for inpatient stay. There were no indications for inpatient admission found based on the medical records.
Per the first reference:
"Risk categorization tools such as the Global Registry of Acute Cardiac Events (GRACE) risk score and the Thrombolysis in Myocardial Infarction (TIMI) risk score can be utilized to assess both the acute and long-term likelihood of a further ischemic event following an NSTEMI. Ischemic risk scores have been found to be superior to clinical assessment alone for this purpose. The results of these risk assessments can thus be useful in patient management. Assessment of acute risk guides initial evaluation and selection of care facility, such as a coronary care unit, and the choice of appropriate pharmacotherapy, and guides decision-making regarding invasive revascularization procedures.
The TIMI and GRACE risk scores do not differentiate between type 1 and type 2 MI; however, patients with type 2 MI could be expected to have higher risk scores based on characteristics included in these risk scores such as older age, comorbidities, and prior history of MI. An analysis comparing the characteristics of patients with type 1 and type 2 MI found that those with type 2 MI had a significantly higher mean GRACE score."
| 1 |
Diagnosis: Thoracic fracture
Treatment: continued subacute rehab
The insurer denied continued subacute rehab.
The patient is a male who has diagnoses of wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture, malignant neoplasm of meninges, benign neoplasm of meninges. His past medical history also includes hypertension, seizure disorder on Keppra, meningioma.
.
Occupational therapy (OT) documents the patient's initial evaluation for lower body (LB) dressing, lower body bathing, toileting as total dependence without attempts to initiate. Upper body (UB) bathing, and UB dressing was max assist. Hygiene/grooming was moderate assist. OT documents that the patient's only change in these ratings is that he did have an attempt to initiate toileting, LB (lower body) dressing and LB bathing but was still max assist. Other domains were unchanged.
Physical therapy documents the patient's initial evaluation for bed mobility as max assistance. Transfers were total dependence without attempts to initiate. The patient was non-ambulatory. Functional transfers were total dependence without attempts to initiate. As of the dates under review, the patient had progressed to mod assistance for functional transfers, 50 feet with two-wheeled walker with contact guard assist (CGA) with mod assistance x 2.
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Upheld
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Medical necessity
|
Diagnosis: Thoracic fracture
Treatment: continued subacute rehab
The insurer denied continued subacute rehab. The health plan's determination is upheld.
The patient is a male who has diagnoses of wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture, malignant neoplasm of meninges, benign neoplasm of meninges. His past medical history also includes hypertension, seizure disorder on Keppra, meningioma.
Continued Subacute Rehabilitation Service is not medically necessary.
Occupational therapy (OT) documents the patient's initial evaluation for lower body (LB) dressing, lower body bathing, toileting as total dependence without attempts to initiate. Upper body (UB) bathing, and UB dressing was max assist. Hygiene/grooming was moderate assist. OT documents that the patient's only change in these ratings is that he did have an attempt to initiate toileting, LB (lower body) dressing and LB bathing but was still max assist. Other domains were unchanged.
Physical therapy documents the patient's initial evaluation for bed mobility as max assistance. Transfers were total dependence without attempts to initiate. The patient was non-ambulatory. Functional transfers were total dependence without attempts to initiate. As of the dates under review, the patient had progressed to mod assistance for functional transfers, 50 feet with two-wheeled walker with contact guard assist (CGA) with mod assistance x 2. Other domains were unchanged.
Criteria for continued Subacute Rehabilitation includes that a patient must have medical necessity for physical, occupational, or speech therapy for a minimum of 1 hour per day and 5 days per week. In addition, documentation must demonstrate sustained gains, progress towards pre-established goals, improvement in function and reduction in limitations. For the time period in question, the patient did not meet these criteria. The patient did not have complex skilled nursing needs, did not require intravenous (iv) or IM (intramuscular) medication management, was not dependent on parenteral nutrition, and did not have complex wound care needs. The patient had made minimal gains in a month of therapy and would not be projected to make substantive further gains that would make continued services medically necessary.
| 1 |
Diagnosis: Heart failure, Shortness of breath.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The patient has a past medical history (PMH) of alcohol dependence, anxiety, coronary artery disease (CAD), liver failure, and severe heart failure with reduced ejection fraction (HFrEF) with ejection fraction (EF) 10% status/post (s/p) implanted cardiac defibrillator who was admitted with complaints of (c/o) shortness of breath associated with increased lower extremity (LE) swelling and orthopnea. Vital signs were notable for a blood pressure (BP) of 92/62. The physical exam was notable for bilateral lower extremity (LE) edema plus (+) 5, speaking full sentences without distress. Lab work was notable for brain (or B-type) natriuretic peptide (BNP) 2470, sodium (Na) 127, magnesium (Mg) 1.2. Imaging studies, a chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed no significant segment (ST) elevations or depressions. The patient was diagnosed with acute on chronic heart failure and treated with intravenous (IV) diuresis, electrolyte repletion, acute coronary
This patient with a known history of heart failure presented to the emergency department (ED) with c/o shortness of breath
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Upheld
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Medical necessity
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Diagnosis: Heart failure, Shortness of breath.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.
The patient has a past medical history (PMH) of alcohol dependence, anxiety, coronary artery disease (CAD), liver failure, and severe heart failure with reduced ejection fraction (HFrEF) with ejection fraction (EF) 10% status/post (s/p) implanted cardiac defibrillator who was admitted with complaints of (c/o) shortness of breath associated with increased lower extremity (LE) swelling and orthopnea. Vital signs were notable for a blood pressure (BP) of 92/62. The physical exam was notable for bilateral lower extremity (LE) edema plus (+) 5, speaking full sentences without distress. Lab work was notable for brain (or B-type) natriuretic peptide (BNP) 2470, sodium (Na) 127, magnesium (Mg) 1.2. Imaging studies, a chest x-ray (CXR) showed no acute disease. An electrocardiogram (EKG) showed no significant segment (ST) elevations or depressions. The patient was diagnosed with acute on chronic heart failure and treated with intravenous (IV) diuresis, electrolyte repletion, acute coronary syndrome (ACS) rule out (r/o), and medication optimization. The patient was discharged against medical advice. At issue is the medical necessity of an inpatient level of care.
No, the admission was not medically necessary at an acute inpatient level of care. This patient with a known history of heart failure presented to the emergency department (ED) with c/o shortness of breath associated with increased LE swelling and orthopnea. The patient was not in acute distress and was hemodynamically stable. Additionally, the patient was not severely compromised, did not have elevated blood urea nitrogen, symptomatic low admission systolic blood pressure, significantly elevated creatinine, severe hyponatremia, cardiac ischemia, airway instability, cardiac arrhythmias requiring continuous intravenous (IV) intervention, or inadequate systemic perfusion, nor did the patient require vasodilator therapy. Finally, the patient's Ottawa Heart Failure Risk Scale (OHFRS)-Heart Failure Risk Score was 0 and the Get With The Guidelines (GWTG)-Heart Failure Risk Score was 41, not consistent with high-risk for serious adverse events. Overall, this patient was monitored, received IV diuresis and this could have been safely provided at a lower level of care.
| 1 |
Diagnosis: Digestive System/Gastrointestinal - Hyperemesis.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
|
Overturned
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Medical necessity
|
Diagnosis: Digestive System/Gastrointestinal - Hyperemesis.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is overturned.
The patient is a female with a history of hyperemesis cannabinoid syndrome who presented with emesis and diarrhea.
She was in her usual state of health until the night prior to presentation when she developed emesis and diarrhea. She described this as a recurrent issue related to her marijuana use and had last smoked marijuana 2 days previously. She was taking antibiotics for Helicobacter (H.) Pylori infection as well as Pepcid, but frequently forgets to take the medications. She also noted weakness and tingling of her hands and feet. She attributed all of these symptoms to marijuana withdrawal.
In the emergency department, her temperature was 38.4 Celsius (C) and her heart rate was 92 beats per minute (bpm). She was described as being in moderate discomfort and she was noted to be actively retching and vomiting bilious content. Laboratory values were obtained which revealed a glucose of 163, a sodium of 132, and a bicarbonate of 17. A chest x-ray was also obtained. She was given intravenous famotidine and ondansetron as well as a normal saline bolus. She was subsequently admitted to the hospital for management of cannabinoid hyperemesis syndrome, with dehydration secondary to recurrent vomiting and diarrhea.
On admission, she continued to vomit several times. She was kept on intravenous fluids, Pepcid, and diphenhydramine as needed (prn). She continued to vomit the next morning and her treatments continued. The following day, her vomiting had resolved. She was able to tolerate oral intake at that time and was felt to be stable for discharge to home with follow up with psychiatry.
The medical necessity for the inpatient stay is under review.
The health plan's determination is overturned.
This is a patient who presented with hyperemesis and dehydration. She was in discomfort at the time of presentation and was actively vomiting. She was dehydrated with a bicarbonate level of 17 and was unable to rehydrate orally due to continued vomiting. She therefore required hospital admission for continued administration of intravenous fluids and Pepcid, along with continuous monitoring.
Patients with cannabinoid hyperemesis syndrome can present with severe nausea and vomiting and abdominal pain. Acute treatment consists of symptomatic care including intravenous fluid hydration and antiemetics. Patients must also be evaluated for other etiologies for the symptoms or potential complications of excessive vomiting. This patient presented with hyperemesis with continued vomiting and dehydration despite appropriate treatment in the emergency department setting. Therefore, she required hospital admission for continued evaluation and treatment with intravenous therapies.
The decision making at the time of admission for this patient was consistent with her age, the presence of hyperemesis with continued active vomiting and dehydration, and the need for ongoing intravenous therapies along with close monitoring for potential deterioration of clinical status.
| 1 |
Diagnosis: Anaphylaxis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay.
The patient is a boy with a history of a nut allergy, who presented to the emergency department with anaphylaxis.
He has a known allergy to nuts and was well until the afternoon of presentation when he ingested chocolate with nuts. He immediately developed difficulty speaking, dysphagia, erythema, and pruritus. He also vomited. He took epinephrine at home and called emergency medical services. The emergency medical services team administered epinephrine, Solu-Medrol, Benadryl, and Zofran. He improved, but while waiting in the emergency department he experienced another episode of throat swelling and flushing. He received another dose of epinephrine at that time, as well as a second dose of Solu-Medrol. He was subsequently admitted for further care for anaphylaxis.
This is a teen boy who presented with significant anaphylaxis requiring extensive treatment both from emergency medical services while in route and in the emergency department. He received 3 doses of epinephrine, as well as 2 doses of
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Overturned
|
Medical necessity
|
Diagnosis: Anaphylaxis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned.
The patient is a boy with a history of a nut allergy, who presented to the emergency department with anaphylaxis.
He has a known allergy to nuts and was well until the afternoon of presentation when he ingested chocolate with nuts. He immediately developed difficulty speaking, dysphagia, erythema, and pruritus. He also vomited. He took epinephrine at home and called emergency medical services. The emergency medical services team administered epinephrine, Solu-Medrol, Benadryl, and Zofran. He improved, but while waiting in the emergency department he experienced another episode of throat swelling and flushing. He received another dose of epinephrine at that time, as well as a second dose of Solu-Medrol. He was subsequently admitted for further care for anaphylaxis.
The Inpatient Hospital Admission was medically necessary for this patient.
Risk factors for biphasic anaphylactic reactions include a severe initial presentation or the need for more than one dose of epinephrine. This patient required 3 doses of epinephrine and 2 doses of Solu-Medrol, raising his risk for recurrent symptoms. An inpatient admission for these patients is indicated to allow for prompt treatment in the case of a biphasic response.
This is a teen boy who presented with significant anaphylaxis requiring extensive treatment both from emergency medical services while in route and in the emergency department. He received 3 doses of epinephrine, as well as 2 doses of Solu-Medrol, due to persistent and severe symptoms of anaphylaxis. He therefore required inpatient admission for ongoing treatment for anaphylaxis, monitoring for potential biphasic reaction, and electrolyte monitoring.
The decision-making at the time of admission for this patient was consistent with his young age, the presence of severe anaphylaxis requiring intensive therapy, and the concern for ongoing symptoms with a potential second phase requiring additional prompt treatment in an inpatient setting to prevent potentially serious morbidity.
| 1 |
Diagnosis: ADHD
Treatment: Assay codes 81225, 81226, 81291, 81231, 81230, 81227
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Upheld
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Experimental/Investigational
|
Diagnosis: ADHD
Treatment: Assay codes 81225, 81226, 81291, 81231, 81230, 81227
The health plan should not cover the proposed treatment.
The assay is not likely to be more beneficial for the patient.
The symptoms described are complex behavioral symptoms requiring multi-modal approaches without being able to attribute the symptoms directly to medication.
Standard of care is to follow treatment algorithms from peer literature and while genetic testing is a patient and provider preference, it does not have literature to support increased efficacy of treatment approaches that include genetic testing over empiric treatment.
| 1 |
Diagnosis: Nasal congestion
Treatment: Current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach
, and code 30117-59 (modifier 59, distinct procedural service)
The insurer denied coverage for current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach
According to the medical records, the patient has nasal congestion and nasal obstruction; the operative note indicates excision of nodular swelling nasal septum for diagnoses of nasal swell bodies and nasal obstruction.
|
Upheld
|
Experimental/Investigational
|
Diagnosis: Nasal congestion
Treatment: Current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service)
The insurer denied coverage for current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service)
The denial is upheld
According to the medical records, the patient has nasal congestion and nasal obstruction; the operative note indicates excision of nodular swelling nasal septum for diagnoses of nasal swell bodies and nasal obstruction.
In this case, there is no documentation in the available medical record of examination findings of an intranasal lesion requiring treatment using current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service).
The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome for current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service).
Current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service) do not need final approval from regulatory bodies for this diagnosis.
This patient is not a good candidate for current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service) based on the submitted medical record.
The adverse risks of current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service) are increased over standard treatment/services in light of no documentation of an intranasal lesion in the submitted medical record.
The requested service current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service) is not likely to be more beneficial than any of the standard treatments/procedures for this patient based on the submitted medical record.
The carrier's denial of the current procedural terminology code 30117 [excision or destruction (e.g., laser) of intranasal lesion; internal approach [when used for nasal septal swell body reduction], and code 30117-59 (modifier 59, distinct procedural service should be upheld.
| 1 |
Diagnosis: Paroxysmal atrial fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The patient has a history of hypertension (HTN), hyperlipidemia (HLD), coronary artery disease (CAD) with previous coronary artery bypass graft (CABG) and mitral valve annuloplasty, and transcarotid artery revascularization. He also has atrial fibrillation, complete heart block and has a permanent dual chamber (left bundle) pacemaker.
He presented for elective catheter ablation for symptomatic, paroxysmal atrial fibrillation. Pulmonary vein isolation was performed as well as a cavotricuspid isthmus ablation for atrial flutter. The procedure was performed without complication and he was discharged.
|
Upheld
|
Medical necessity
|
Diagnosis: Paroxysmal atrial fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.
The patient has a history of hypertension (HTN), hyperlipidemia (HLD), coronary artery disease (CAD) with previous coronary artery bypass graft (CABG) and mitral valve annuloplasty, and transcarotid artery revascularization. He also has atrial fibrillation, complete heart block and has a permanent dual chamber (left bundle) pacemaker.
He presented for elective catheter ablation for symptomatic, paroxysmal atrial fibrillation. Pulmonary vein isolation was performed as well as a cavotricuspid isthmus ablation for atrial flutter. The procedure was performed without complication and he was discharged.
At issue is the medical necessity of an inpatient stay.
No, inpatient stay was not medically necessary for this patient who presented for elective catheter ablation for paroxysmal atrial fibrillation. The procedure was uncomplicated and he was discharged on the same day. This is generally considered an outpatient or observation status procedure, per Milliman Guidelines and standard of care, as noted in the multicenter, retrospective study by Bailey, et al. (reference 3 below). Care could have been provided at a lower level than inpatient.
| 1 |
Diagnosis: Bone loss
Treatment: D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on All Four Quadrants
The insurer denied the D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on
The patient is a female whose dentist is requesting treatment of a crown for tooth #10 and four quadrants of deep cleaning (scaling and root planning.) Per the narrative submitted by the patient's dentist, the patient had hot and cold sensitivity, pain and bleeding from tooth #10 and there was a deep existing composite resin filling in place. The dentist reported the nerve of the tooth because infection and inflamed at the apex and root canal treatment was necessary and subsequently performed. The dentist also stated "Patient has trauma to the tooth" but did not explain how, when or the extent of the trauma. The dentist further stated, "the tooth is grossly discolored and traumatized, is very brittle, and
PFM" (crown) "tooth is now a shade of blue and grey."
The patient's dentist also submitted a periapical x-ray of tooth #10 (pre- and post-operative), periodontal charting and a panoramic x-ray. Review of pre-operative PA X-ray
a small composite restoration on tooth #10. It also shows localized bone loss distal of #10. Periodontal charting reveals a probing depth of 4 mm (millimeters) at the distal of tooth #10.
|
Upheld
|
Medical necessity
|
Diagnosis: Bone loss
Treatment: D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on All Four Quadrants
The insurer denied the D2750 White Glass with High Gold Content Crown Tooth 10, D4341 Deep Gum and Root Cleaning, Lower on All Four Quadrants
The denial is upheld
The patient is a female whose dentist is requesting treatment of a crown for tooth #10 and four quadrants of deep cleaning (scaling and root planning.) Per the narrative submitted by the patient's dentist, the patient had hot and cold sensitivity, pain and bleeding from tooth #10 and there was a deep existing composite resin filling in place. The dentist reported the nerve of the tooth because infection and inflamed at the apex and root canal treatment was necessary and subsequently performed. The dentist also stated "Patient has trauma to the tooth" but did not explain how, when or the extent of the trauma. The dentist further stated, "the tooth is grossly discolored and traumatized, is very brittle, and may break down further without PFM" (crown) "tooth is now a shade of blue and grey."
The patient's dentist also submitted a periapical x-ray of tooth #10 (pre- and post-operative), periodontal charting and a panoramic x-ray. Review of pre-operative PA X-ray provided reveals a small composite restoration on tooth #10. It also shows localized bone loss distal of #10. Periodontal charting reveals a probing depth of 4 mm (millimeters) at the distal of tooth #10. The x-ray of the pre-operative status of the tooth and after the tooth had root canal treatment do not show decay or significant breakdown such that the tooth is compromised or the crown portion of the tooth is weakened at risk for fracture. There was no mention of the occlusal relationship of #10 with any other tooth. The panoramic x-ray provided is not diagnostic for generalized bone loss in any of the four quadrants. The only apparent bone loss is at the distal of tooth #10. The requested services were previously denied because tooth #10 "does not seem to have significant breakdown due to decay or trauma" and "there is no evidence of significant bone loss" to support the need for scaling and root planing.
No, the proposed treatment is not medically necessary.
There was no description by the patient's dentist to show pathologic destruction to more than 50% of the crown of tooth #10 (to include incisal edge and incisal line angle or 4 or more surfaces.) Due to lack of evidence of decay or trauma, and lack of clinical description of breakdown of the crown of the tooth, a porcelain fused to metal (PFM) crown for tooth #10 is not medically necessary at this time.
Scaling and root planing is indicated for acute periodontal disease which is diagnosed based on clinical and radiographic assessment. There was no narrative about oral hygiene status or clinical description of the quality of gum tissue, nor presence of calculus, bleeding index, mobility, furcation status or diagnosis of bone loss. The patient's dentist did not provide a diagnosis of periodontal disease for this patient. Further, the provided x-rays did not show significant bone loss (2.5+ (plus) mm (millimeters) from the cemento-enamel junction) or radiographic evidence of subgingival calculus in any of the four quadrants. While the submitted periodontal charting shows 2-7 mm (millimeters) probing depths for this patient, there is no evidence of radiographic calculus or bone loss. Therefore, four quadrants of scaling and root planing is not medically necessary for this patient.
Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The health plan used the provided X-rays, periodontal charting and clinical description of tooth #10 to determine if the requested services of D2750 and D4341 x 4 quadrants were medically necessary for this patient.
| 1 |
Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The
.
The patient is an adult male with chronic low back pain of several years' duration. He has trialed multiple treatments including acupuncture, chiropractic care, heat/ice, injections, lumbar epidural steroid injections, medial branch block injections, medications, and physical therapy. The pain greatly impacts his ability to complete activities of daily living especially with
changing positions. Nothing has provided sustainable relief. His pain ranges from 6-10/10. Magnetic resonance imaging (MRI) of the lumbar spine with Modic changes at disc spaces L3-4, L4-5, and L5-S1 according to provider review. Official radiology read with multilevel degenerative changes and showed no report of degenerative endplate changes or Modic changes. Physical exam revealed 5/5 strength, negative Hoffman's sign, positive straight leg, and negative sacroiliac joint and facet loading maneuvers. The provider requested basivertebral ablation of L3, L4, L5, and S1 vertebral bodies to treat vertebrogenic pain. This was
|
Upheld
|
Experimental/Investigational
|
Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The denial is upheld.
The patient is an adult male with chronic low back pain of several years' duration. He has trialed multiple treatments including acupuncture, chiropractic care, heat/ice, injections, lumbar epidural steroid injections, medial branch block injections, medications, and physical therapy. The pain greatly impacts his ability to complete activities of daily living especially with
changing positions. Nothing has provided sustainable relief. His pain ranges from 6-10/10. Magnetic resonance imaging (MRI) of the lumbar spine with Modic changes at disc spaces L3-4, L4-5, and L5-S1 according to provider review. Official radiology read with multilevel degenerative changes and showed no report of degenerative endplate changes or Modic changes. Physical exam revealed 5/5 strength, negative Hoffman's sign, positive straight leg, and negative sacroiliac joint and facet loading maneuvers. The provider requested basivertebral ablation of L3, L4, L5, and S1 vertebral bodies to treat vertebrogenic pain. This was denied by the health plan as investigational/experimental. The denial is being appealed.
The health plan should not cover the requested health service.
The Intracept procedure is a relatively novel procedure used to treat vertebrogenic axial back pain. In properly selected patients with chronic low back pain, the SMART and SMART 24 randomized controlled trials (RCTs) demonstrated significant pain relief. In fact, close to 50% of the patients were able to cease opioid use for chronic low back pain. The procedure has been proven safe and effective and is United States Food and Drug Administration (FDA) approved. Treatment should be considered when all conservative measures have tried and failed and when the patient has clear Modic changes on magnetic resonance imaging. There is level 1 evidence for its safety and efficacy and, therefore, it would not be considered experimental/investigational for properly selected patients. The cohorts used in the SMART and SMART 24 trials were large (over 200 people) with statistically significant results. More recent 5-year data from the ongoing SMART study demonstrated that 66% of patients reported 50% reduction in pain, 47% reported a greater than 75% reduction in pain, and 34% had complete pain resolution. As mentioned by the provided appeal letter, clinical summary, and robust reference bibliography, several societies including American Society of Pain and Neuroscience (ASPN) and North American Spine Society (NASS) have given basivertebral nerve (BVN) ablation level A grade evidence with high certainty that the net benefit is substantial in appropriately selected pain patients. The patient in this case has had chronic low back pain for more than 6 months; has failed conservative treatment including medications, injections, physical therapy, and acupuncture; and has significant functional decline and inability to complete activities of daily living due to his pain. However, the reported magnetic resonance imaging of the lumbar spine is from 2 years ago, and there is no official read noting Modic changes and/or endplate degenerative changes as reported by the requesting provider. Therefore, this procedure is not considered medically appropriate for this patient.
| 1 |
Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Qulipta.
.
The patient is a female diagnosed with migraine. Treatment with Qulipta is the subject of this review. The drug was denied because the member has not tried and failed available formulary alternatives such as Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The provider appealed the determination.
There is no documentation that the member has tried and failed any of the following formulary drugs: Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The physician indicates that the member has tried and failed topiramate, verapamil, and indomethacin for prevention of migraine.
|
Upheld
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Formulary Exception
|
Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Qulipta.
The denial is upheld.
The patient is a female diagnosed with migraine. Treatment with Qulipta is the subject of this review. The drug was denied because the member has not tried and failed available formulary alternatives such as Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The provider appealed the determination.
There is no documentation that the member has tried and failed any of the following formulary drugs: Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The physician indicates that the member has tried and failed topiramate, verapamil, and indomethacin for prevention of migraine. Of these, only topiramate is generally considered to be an effective migraine prevention agent. The physician notes that the patient may instead have a trigeminal autonomic cephalgia.
The health plan's determination is upheld.
Qulipta has not been compared head to head with the formulary agents of Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. As such, there are no data to show that Qulipta will be more or less effective than these alternatives.
However, drugs such as Ajovy, Aimovig, and Emgality are Food and Drug Administration (FDA) approved for prevention of episodic and chronic migraine. Literature shows that use of these medications results in a statistically significant decrease in migraine frequency. The member does not have an absolute medical contraindication to the use of these drugs or any of the formulary alternatives. Similar to Qulipta, Ajovy, Aimovig, and Emgality modulate the Calcitonin Gene-Related Peptide (CGRP) pathway and usually do not have any clinically significant side effects.
| 1 |
Diagnosis: Anorexia nervosa.
Treatment: Non-emergency air/ground ambulance transport.
The insurer denied Non-emergency air/ground ambulance transport.
involves a young adult female diagnosed with an eating disorder with severe anorexia nervosa and comorbid symptoms of anxiety, depression and passive suicidal ideation. The patient has a history of treatment in multiple eating disorder programs without sustained benefit or remission of symptoms, and she has had general medical complications in the context of worsening symptoms of the eating disorder and comorbid psychiatric conditions including major depressive disorder, generalized anxiety disorder and posttraumatic stress disorder (PTSD) with a history of childhood sexual abuse as a precipitating factor with the eating disorder. Medical complications include cardiac disease with long QT syndrome and sick sinus syndrome and abnormal electrocardiogram (EKG), slow transit constipation and gastroparesis, malnutrition with placement of a percutaneous endoscopic gastrostomy (PEG) tube for feeding due to restrictive intake, orthostatic hypotension (postural orthostatic tachycardia syndrome (POTS), and electrolyte abnormality with hypokalemia, as well as a body mass index (BMI) at 14.5 with weight at 81.9 lbs. and height at five feet and three inches.
In this case, the patient is diagnosed with severe symptoms of anorexia nervosa including comorbidity with anxiety and depression and trauma history, as well as passive suicidal ideation and extensive, life-threatening general
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Overturned
|
Medical necessity
|
Diagnosis: Anorexia nervosa.
Treatment: Non-emergency air/ground ambulance transport.
The insurer denied Non-emergency air/ground ambulance transport.
The health plan's determination is overturned.
This case involves a young adult female diagnosed with an eating disorder with severe anorexia nervosa and comorbid symptoms of anxiety, depression and passive suicidal ideation. The patient has a history of treatment in multiple eating disorder programs without sustained benefit or remission of symptoms, and she has had general medical complications in the context of worsening symptoms of the eating disorder and comorbid psychiatric conditions including major depressive disorder, generalized anxiety disorder and posttraumatic stress disorder (PTSD) with a history of childhood sexual abuse as a precipitating factor with the eating disorder. Medical complications include cardiac disease with long QT syndrome and sick sinus syndrome and abnormal electrocardiogram (EKG), slow transit constipation and gastroparesis, malnutrition with placement of a percutaneous endoscopic gastrostomy (PEG) tube for feeding due to restrictive intake, orthostatic hypotension (postural orthostatic tachycardia syndrome (POTS), and electrolyte abnormality with hypokalemia, as well as a body mass index (BMI) at 14.5 with weight at 81.9 lbs. and height at five feet and three inches.
The Non-Emergency Air and Ground Ambulance Services from private residence to Acute Center for Eating Disorders was medically necessary for this patient.
In this case, the patient is diagnosed with severe symptoms of anorexia nervosa including comorbidity with anxiety and depression and trauma history, as well as passive suicidal ideation and extensive, life-threatening general medical complications of malnutrition. The transfer from her home an acute care facility was clinically appropriate and medically necessary in this case scenario. The patient had failed to benefit from treatment at multiple other facilities without sustained benefit and worsening clinical course. The treatment facility was the most appropriate treatment facility to address the multiple general medical complications associated with the eating disorder and to provide the general medical services and comprehensive behavioral health and psychiatric services that were medically necessary and clinically appropriate for this patient. The transport by air ambulance was also medically necessary due to the need for monitoring and support during the transport, as outlined in the clinical summary. Transport by ground transport and commercial airline was not feasible and dangerous in this case scenario. The receiving treatment facility is the closest treatment facility that is/was capable of addressing the medical needs of the patient, and the air ambulance transport (including ground transport) was in the patient's best interest and appropriate.
| 1 |
Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
|
Upheld
|
Medical necessity
|
Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied the inpatient stay.
The denial is upheld.
The patient is a male with unremarkable past medical history who presented to the emergency department with right lower quadrant abdominal pain that started one day before the presentation. The patient described the pain as sharp. It was associated with nausea and vomiting. The patient denied any previous similar episodes. The patient denied diarrhea, fever, chest pain, cough, or shortness of breath.
At the time of the initial evaluation, he was afebrile. The respiratory rate was 16 breaths/min, blood pressure was 117/55, oxygen saturation was 98% on room air.
The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. There was regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, tender to palpation in the right lower quadrant with rebound tenderness. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that white blood cell count was 14.06, hemoglobin was 15.2, hematocrit was 44.5, and platelets were 201. Sodium was 139, potassium was 4.1, chloride was 108, bicarbonate was 26, blood urea nitrogen (BUN) was 16, creatinine was 1.06, and glucose was 144. Liver function tests were within normal limits. Urinalysis was unremarkable.
Computed tomography (CT) scan of the abdomen and pelvis revealed findings most consistent with early acute appendicitis.
The patient was admitted to the hospital with acute appendicitis and leukocytosis.
In the hospital, the patient was evaluated by the general surgery service who suggested that he had acute appendicitis and recommended laparoscopic appendectomy.
The appendectomy was performed. In the postoperative period, the patient developed urinary retention that resolved quickly and was started on Flomax.
Overall, this patient remained in stable clinical condition and was discharged from the hospital.
The subject under review is the medical necessity for the inpatient stay.
The health plan's determination is upheld in whole.
Based on the current standards of care, the admission for treatment of acute uncomplicated appendicitis, including surgical intervention, is usually conducted at a lower level of care status.
In this clinical case, the patient remained afebrile and hemodynamically stable during the entire hospitalization. The patient underwent an uncomplicated laparoscopic appendectomy.
Following the appendectomy, the patient tolerated his diet.
The review of the medical records demonstrated no significant laboratory abnormalities that would necessitate the care at the acute inpatient level. The urinary retention after the surgery was short-lived and did not necessitate any interventions requiring admission at the acute inpatient level of care.
The review of the medical records did not demonstrate any circumstances that would justify the acute inpatient level of care in this clinical case. The patient could have been managed at a lower level of care status.
| 1 |
Diagnosis: Skin/Plaque Psoriasis
Treatment: Pharmacy/Prescription Drugs/Taltz
The health plan denied the requested exception for a prescription drug because it did not meet the plan's criteria.
The patient is a male with psoriasis. The patient has tried and failed topical agents such as 0.05% augmented Betamethasone Dipropionate cream, 0.1% Tacrolimus ointment, and 0.1% Triamcinolone Acetonide cream, Taclonex Scalp, and Olux-E. The patient has tried and failed Humira, Stelara, and Ilumya, but has had good improvement on Cosentyx, but it did not clear his psoriasis, according to the clinic records.
|
Upheld
|
Formulary Exception
|
Diagnosis: Skin/Plaque Psoriasis
Treatment: Pharmacy/Prescription Drugs/Taltz
The health plan denied the requested exception for a prescription drug because it did not meet the plan's criteria.
The health plan's determination is upheld.
The patient is a male with psoriasis. The patient has tried and failed topical agents such as 0.05% augmented Betamethasone Dipropionate cream, 0.1% Tacrolimus ointment, and 0.1% Triamcinolone Acetonide cream, Taclonex Scalp, and Olux-E. The patient has tried and failed Humira, Stelara, and Ilumya, but has had good improvement on Cosentyx, but it did not clear his psoriasis, according to the clinic records.
The health plan's determination of Taltz is upheld.
The patient has no documented treatment failure with, or true medical contraindication to, either Otezla, Cimzia, Skyrizi, or Tremfya. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition, as is the requested Taltz. Therefore, as per the patient's health plan policy language, [1] the requested Taltz is not medically necessary.
Modern dermatology literature [2-5] supports the use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with this particular history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. There is documentation of improvement while on Cosentyx, but the failure of this medication, which has a very similar level of efficacy and mechanism of action as the requested Taltz, to clear this patient's psoriasis suggests that this patient (who is starting the lower/monthly maintenance dosing of Taltz) has significant risk of treatment failure while on the maintenance dose of Taltz.
Taltz appears to being used out of convenience instead of true medical necessity. Therefore, as per current medical standards of care, Taltz is neither likely to be more effective than formulary alternatives, or have less adverse effects than formulary alternatives, and is therefore not medically necessary for health plan coverage.
| 1 |
Diagnosis: Respiratory System - Shortness of breath.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The patient is a male with hypertension, polysubstance abuse (ecstasy, cocaine, alcohol, tobacco), and asthma who was sent to the emergency room (ER) for detoxification and complaints of shortness of breath, chest tightness and difficulty breathing. He had presented to another hospital the day before with similar symptoms. Last cocaine and ecstasy was the day prior to presentation. Physical exam documented by the ER physician noted wheezing and rhonchi. Peak expiratory flow was 280 liters per minute (L/min.). Electrocardiogram (EKG) showed sinus rhythm [HR (heart rate) 98] and a corrected QT interval (QTc) of 492. Vital signs documented the temperature at 36.7 degrees Celsius, heart rate (HR) 104, respiratory rate (RR) 18, blood pressure (BP) 171/113, with oxygen saturation of 97% on room air. Labs were notable for a urine toxicology screen positive for cocaine, venous blood gas (VBG) 7.35 | 48| 55, otherwise labs were unremarkable. Chest x-ray was unremarkable. The patient was given albuterol / levalbuterol, antihypertensives (oral), methylprednisolone, and famotidine in the ER. The patient was admitted with concern that his QTc interval was prolonged. He received duo-nebs and prednisone. He was monitored for withdrawal from alcohol and other substances. QTc returned to normal limits. Elect
|
Upheld
|
Medical necessity
|
Diagnosis: Respiratory System - Shortness of breath.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is upheld.
The patient is a male with hypertension, polysubstance abuse (ecstasy, cocaine, alcohol, tobacco), and asthma who was sent to the emergency room (ER) for detoxification and complaints of shortness of breath, chest tightness and difficulty breathing. He had presented to another hospital the day before with similar symptoms. Last cocaine and ecstasy was the day prior to presentation. Physical exam documented by the ER physician noted wheezing and rhonchi. Peak expiratory flow was 280 liters per minute (L/min.). Electrocardiogram (EKG) showed sinus rhythm [HR (heart rate) 98] and a corrected QT interval (QTc) of 492. Vital signs documented the temperature at 36.7 degrees Celsius, heart rate (HR) 104, respiratory rate (RR) 18, blood pressure (BP) 171/113, with oxygen saturation of 97% on room air. Labs were notable for a urine toxicology screen positive for cocaine, venous blood gas (VBG) 7.35 | 48| 55, otherwise labs were unremarkable. Chest x-ray was unremarkable. The patient was given albuterol / levalbuterol, antihypertensives (oral), methylprednisolone, and famotidine in the ER. The patient was admitted with concern that his QTc interval was prolonged. He received duo-nebs and prednisone. He was monitored for withdrawal from alcohol and other substances. QTc returned to normal limits. Electrolytes remained within normal limits. The patient was discharged. The subject under review is the medical necessity for the inpatient stay.
The health plan's determination is upheld.
The inpatient stay is not medically necessary for this patient. Services could have been rendered appropriately at a lower level of care status. The patient presented to the ER with symptoms of shortness of breath and dyspnea with exertion with vitals that were within normal limits, with no need for supplemental oxygen, and a VBG with appropriate potential hydrogen (pH), elevated carbon dioxide (CO2) in the setting of a RR within normal limits not indicating patient was going to tire out. The patient was documented to be wheezing and have expiratory rhonchi. Peak expiratory flow documented at 280 L/min. Predicted is 431 L/min - 570 L/min (Hankinson et al.). Unclear what his baseline peak expiratory flow rate (PEFR) was. Given the patient has a history of substance abuse (cocaine, tobacco), peak expiratory flow would be predicted to be lower. Even if the patient's baseline peak expiratory flow rate was at the maximum (570 L/min), his current peak expiratory flow rate was 50% of possible peak which would be classified as moderate obstruction, but again his personal best flow rate is unknown (Choi et al.). He received treatment in the ER but continued to have symptoms despite not having vital sign changes or evidence of respiratory distress indicating a need to admit the patient for monitoring and symptom management (Wollard et al.). Cocaine is likely to cause the patient's symptoms in the setting of presumed underlying lung disease from chronic use of adulterant substances and tobacco (Tseng et al.). QTc prolongation is common in patients who utilize cocaine and patients who utilize cocaine have a higher risk of arrhythmias (Taylor et al.).
Based on this information, the patient would be expected to have symptom relief within 24-48 hours of admission and decline in QTc to within normal limits with elimination of cocaine (Wollard et al., Tseng et al., Taylor et al.). Therefore, patient would not be expected to stay longer than 48 hours or less than 2 midnights. The patient could have been safely treated at a lower level of care status.
| 1 |
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Stay.
|
Upheld
|
Medical necessity
|
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Stay.
The denial is upheld.
The patient is a female with a past medical history significant for Meniere's disease who presented to the hospital after she sustained a fall. The patient slipped on ice and landed on steps. Following the fall, she presented to the emergency department where she was diagnosed with multiple thoracic and lumbar transfers process fractures. She was seen by the trauma surgery team. Subsequently, she came back with complaints of increasing back pain that was unrelieved with analgesics. The patient denied bladder or bowel dysfunction or shooting pain in the lower extremities. The computed tomography (CT) scan of the lumbar spine that was performed on the day of admission demonstrated fractures of the 11th and 12th thoracic vertebra as well as a 1.7 centimeter (cm) splenic laceration.
When the patient was seen by the admitting physician, she was afebrile. Her pulse rate was 78 beats per minute (bpm), respiratory rate was 18 breaths per minute, blood pressure was 113/58, and oxygen saturation was 96% on room air. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. There was tenderness in the posterior lower left side of the chest. There was mild tenderness in the left upper quadrant without guarding or rebound. The patient was able to move all four extremities. Motor function and sensation were grossly intact. There was lower thoracic and lumbar tenderness appreciated with no cervical spine tenderness. The patient was admitted to the hospital and multimodal pain control was initiated. The patient was started on a regular diet and was recommended to utilize an incentive spirometer.
On the next day after the day of admission, it was reported that the patient had no new complaints. The pain improved, and the patient denied shortness of breath. The patient remained afebrile and hemodynamically stable. The oxygen saturation was 96% on room air. The laboratory evaluation revealed that the white blood cell count was 4.9, hemoglobin was 11.8, hematocrit was 36.8, and platelets were 152. The sodium was 140, potassium was 4.2, chloride was 110, bicarbonate was 25, blood urea nitrogen (BUN) was 20, creatinine was 0.8, and glucose was 89.
According to the medical records, the patient was followed by the surgical service who stated in the progress note that the patient's pain was well-controlled. The hemoglobin remained stable. Therefore, the patient was cleared for discharge by the trauma surgery team.
At issue is the medical necessity of the Inpatient Stay.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Inpatient Stay was not medically necessary for this patient.
Overall, the patient remained in stable clinical condition. Her pain was well-controlled within a short period of time after admission, and she was able to transition to oral pain medications. The review of the medical records demonstrated that despite the injuries that the patient sustained as a result of the fall, she remained hemodynamically stable. Her pain became well-controlled within a short period of time after admission. This patient did not need any interventions or diagnostic studies requiring admission at the acute inpatient level of care. Despite spleen laceration, the patient's hemoglobin remained stable, and she had no significant bleeding requiring intervention.
Taking into consideration all these facts, and given the clinical circumstances, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay was not medically necessary.
| 1 |
Diagnosis: Family history of cancer
Treatment: Guideline Based Hereditary Cancer Panel
The insurer denied Guideline Based Heredita
The patient is a female with a family history of colon and ovarian cancer. Her significant (1st or 2nd degree) family history includes a mother with colon cancer, maternal grandfather with colon cancer, a maternal uncle with colon cancer and 2 maternal aunts with colon cancer. The ovarian cancer is a distant relative and not a first or second degree relative. She was tested for the
|
Upheld
|
Experimental/Investigational
|
Diagnosis: Family history of cancer
Treatment: Guideline Based Hereditary Cancer Panel
The insurer denied Guideline Based Hereditary Cancer Panel.
The health plan's determination is upheld.
The patient is a female with a family history of colon and ovarian cancer. Her significant (1st or 2nd degree) family history includes a mother with colon cancer, maternal grandfather with colon cancer, a maternal uncle with colon cancer and 2 maternal aunts with colon cancer. The ovarian cancer is a distant relative and not a first or second degree relative. She was tested for the Guideline Cancer panel and this is under review.
The proposed Guideline Based Hereditary Cancer Panel is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a maternal family history of colon cancer. This test is utilized primarily by a person with a personal history of cancer who have tested negative for a single gene or syndrome, but who's personal or family history remains strongly suggestive of an inherited susceptibility. It can also be utilized for a family history of several different types of cancer that do not seem to fit a particular hereditary cancer syndrome. This patient does not have a personal history of cancer, has not been tested for specific genes regarding her family history of colon cancer and does not have several/various types of cancers in her family. It would be beneficial and standard of care to test her maternal relatives with colon cancer if possible, for specific colon cancer gene mutations first. Therefore, the requested testing is not likely to be more beneficial than standard treatment in this case.
| 1 |
Diagnosis: Sickle Cell Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The
The patient is a male with diagnosis of sickle cell crisis with review for inpatient hospital admission.
The patient presented with history of sickle cell disease, glaucoma, constipation, and reflux due to severe chest and right upper arm pain. This is consistent with a prior vaso-occlusive cell crisis and the patient had not responded to treatment with Tylenol at home. On examination the patient had tenderness to the sternum. Laboratory evaluation demonstrated white blood cell count of 13.9, hemoglobin 10.9, and sinus rhythm on EKG (electrocardiogram) was noted. Chest radiograph was negative for acute pulmonary disease. The patient was administered IV (intravenous) fluids, IV (intravenous) morphine and ibuprofen. The patient was admitted and managed for pain. No fevers.
In this case the patient was admitted with a vaso-occlusive pain crisis and remained in the hospital for 24 hours. The patient was managed with IV (intravenous) narcotics.
|
Upheld
|
Medical necessity
|
Diagnosis: Sickle Cell Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld
The patient is a male with diagnosis of sickle cell crisis with review for inpatient hospital admission.
The patient presented with history of sickle cell disease, glaucoma, constipation, and reflux due to severe chest and right upper arm pain. This is consistent with a prior vaso-occlusive cell crisis and the patient had not responded to treatment with Tylenol at home. On examination the patient had tenderness to the sternum. Laboratory evaluation demonstrated white blood cell count of 13.9, hemoglobin 10.9, and sinus rhythm on EKG (electrocardiogram) was noted. Chest radiograph was negative for acute pulmonary disease. The patient was administered IV (intravenous) fluids, IV (intravenous) morphine and ibuprofen. The patient was admitted and managed for pain. No fevers.
The proposed treatment at an inpatient level of care would not be considered medically necessary.
In this case the patient was admitted with a vaso-occlusive pain crisis and remained in the hospital for 24 hours. The patient was managed with IV (intravenous) narcotics. His pain resolved. Clinical indications for inpatient level of care admission for a patient with sickle cell complications include the patient having stroke, seizure, other significant central nervous system event, acute chest syndrome, need for oxygen, fever/infection, or persistent pain that cannot be managed in an observation level of care and timeframe. In this case there is no evidence of any significant sickle cell complication to include aplastic crisis, priapism, hyphema, acute chest syndrome, severe infection or any other treatment that would be deemed medically necessary and inpatient level of care such as prolonged oxygen requirement, prolonged parenteral narcotic requirement, exchange transfusion or any other treatment requiring inpatient level of care. As such, this patient could have been safely and effectively managed at a lower level of care such as observation.
Yes; the health plan determined the safe and effective level care for this patient based on the clinical information provided. In this case the plan made a correct assessment that inpatient level of care would not be considered medically necessary given the patient's presentation, short stay, resolution of pain symptoms and other clinical factors to differentiate observation level of care versus inpatient level of care.
| 1 |
Diagnosis: Myelodysplastic syndrome.
Treatment: 81455 - Comprehensive Genomic Profile.
The insurer denied the 81455 - Comprehensive Genomic Profile.
The patient in this case was diagnosed with myelodysplastic syndrome after presenting with leukopenia and anemia. Conventional cytogenetics were performed and were normal. Molecular testing was done using a panel.
|
Overturned
|
Experimental/Investigational
|
Diagnosis: Myelodysplastic syndrome.
Treatment: 81455 - Comprehensive Genomic Profile.
The insurer denied the 81455 - Comprehensive Genomic Profile.
The denial is overturned.
The patient in this case was diagnosed with myelodysplastic syndrome after presenting with leukopenia and anemia. Conventional cytogenetics were performed and were normal. Molecular testing was done using a panel.
Yes, the health plan should cover the proposed treatment.
Many different gene mutations can be identified in patients diagnosed with myelodysplastic syndrome. It is currently considered standard of care to perform molecular profiling in all cases of myelodysplastic syndromes. This information is important in assigning prognosis, which has a direct impact on treatment decisions. National Comprehensive Cancer Network (NCCN) guidelines recommend routinely testing for gene mutations in many different genes based on their documented impact on prognosis assessment and thereby recommendations for treatment. Given NCCN endorsement of this type of testing it should be covered by the health plan.
Yes, the requested health service is more beneficial than any standard treatment for the insured condition.
Molecular testing such as was done in this case is currently considered a standard test for patients diagnosed with myelodysplastic syndromes, as noted above.
| 1 |
Diagnosis: Multifibroid uterus
Treatment: Ambulatory surgery - radiofrequency ablation [0404T x (times) 1]
The insurer denied the Ambulatory surgery - radiofrequency ablation [0404Tx1].
.
The patient is a female with a multifibroid uterus. She has heavy menstrual bleeding, dysmenorrhea, and pelvic pressure. She has had a prior dilation and curettage (D&C). She desires uterine preservation. The plan is for Sonata.
|
Upheld
|
Experimental/Investigational
|
Diagnosis: Multifibroid uterus
Treatment: Ambulatory surgery - radiofrequency ablation [0404T x (times) 1]
The insurer denied the Ambulatory surgery - radiofrequency ablation [0404Tx1].
The denial is upheld.
The patient is a female with a multifibroid uterus. She has heavy menstrual bleeding, dysmenorrhea, and pelvic pressure. She has had a prior dilation and curettage (D&C). She desires uterine preservation. The plan is for Sonata. This is denied as not medically necessary. This is being appealed.
No, the health plan should not cover the proposed treatment.
According to the American College of Obstetrics and Gynecology (ACOG), "There are a variety of treatment options for leiomyomas, including expectant, medical, interventional, and surgical therapies. Although evidence exists regarding outcomes with specific therapies, comparative effectiveness data are lacking for leiomyoma management options. When considering treatment options, patient-specific symptoms and severity should be addressed. If a patient describes symptoms that are neither severe, nor debilitating, expectant management may be appropriate. Medical treatments primarily address bleeding symptoms. Procedural interventions and surgical approaches treat bulk symptoms by decreasing uterine mass."
The American College of Obstetrics and Gynecology (ACOG) states that "Focused ultrasound surgery, guided by diagnostic ultrasound or magnetic resonance, is a noninvasive treatment modality that uses multiple high-intensity ultrasound waves to cause coagulative necrosis of uterine leiomyomas. Currently only magnetic resonance-guided focused ultrasound is FDA (United States Food and Drug Administration) approved for the treatment of uterine leiomyomas. Limited, low-quality data suggest that magnetic resonance-guided focused ultrasound and high-intensity focused ultrasound are associated with a reduction in leiomyoma and uterine size. However, small randomized comparative trial data suggest that compared with UAE (Uterine artery embolization), magnetic resonance-guided focused ultrasound is associated with less improvement in symptoms and quality-of-life measures and a higher risk of reintervention. In a recent meta-analysis, the rate of reintervention at 60 months was 53.9% [percent]. Additional data are needed before recommendations can be made regarding the use of this treatment for uterine leiomyomas."
The American College of Obstetrics and Gynecology (ACOG) reports that "Radiofrequency ablation (RFA) can be delivered by a laparoscopic, transvaginal, or transcervical approach, using ultrasound guidance to induce coagulative necrosis in targeted uterine leiomyomas. All of the approaches are similarly effective in reducing uterine leiomyoma volume and in improving quality of life metrics, but the laparoscopic approach has been studied the most rigorously. Although RFA (Radiofrequency ablation) is a reasonable option to consider for the treatment of symptomatic uterine leiomyomas, access to this technology is currently limited."
Although there have been studies performed on the Sonata system, studies are still needed that compare this treatment to the standard treatments. There are not any large randomized controlled trials or large observational trials that provide evidence that this procedure is better than the alternative options. There is also no data to support use of this procedure as being effective and safe long term in patients with symptomatic uterine myomas as compared to other alternatives. This procedure is also not endorsed by the American College of Obstetrics and Gynecology (ACOG), who provides the guidelines for obstetricians and gynecologists (OB/GYNs) in the United States. Therefore this is not considered a standard of medical practice at this time. The plan does not cover procedures that are not considered a standard of medical practice.
No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
Standard alternatives include hystereoscopic myomectomy, laparoscopic myomectomy, and Accessa.
| 1 |
Diagnosis: Class I skeletal occlusion.
Treatment: D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition;
D8670 - Periodic Orthodontic Treatment visits.
The insurer denied the D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition; D8670 - Periodic Orthodontic Treatment visits.
.
The patient is a female requesting orthodontic benefits. The prior denial was due to a Handicapping index score of 16 which is shy of the 26 threshold. The patient has a Class I skeletal occlusion with moderate upper and lower crowding.
.
The patient has a deep, impinging overbite with soft tissue damage on her palate.
|
Overturned
|
Medical necessity
|
Diagnosis: Class I skeletal occlusion.
Treatment: D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition;
D8670 - Periodic Orthodontic Treatment visits.
The insurer denied the D8080 - Comprehensive Orthodontic Treatment of the Adolescent Dentition; D8670 - Periodic Orthodontic Treatment visits. The denial is overturned.
The patient is a female requesting orthodontic benefits. The prior denial was due to a Handicapping index score of 16 which is shy of the 26 threshold. The patient has a Class I skeletal occlusion with moderate upper and lower crowding.
Yes, the proposed treatment is medically necessary.
The patient has a deep, impinging overbite with soft tissue damage on her palate. This is an automatic qualifier according to the Handicapping Index scale. This case has medical necessity and needs orthodontic treatment to correct the problem.
No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
| 1 |
Diagnosis: Hypertension, cardiac arrhythmias, asthma, arthritis, general weakness, gait abnormalities, and overactive bladder
Treatment: increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The insurer denied coverage for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
|
Upheld
|
Formulary Exception
|
Diagnosis: Hypertension, cardiac arrhythmias, asthma, arthritis, general weakness, gait abnormalities, and overactive bladder
Treatment: increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The insurer denied coverage for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The denial is overturned
This is an elderly patient with chronic medical problems including hypertension, cardiac arrhythmia and osteoarthritis. The insurer approved consumer directed personal assistant services (CDPAS) 42 hours/week. The request is for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.
The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. Maximal to extensive assistance is needed for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing. Extensive assistance is needed for personal hygiene, dressing, locomotion, ambulation (uses walker or cane) and toilet transfer/use. She is frequently incontinent of bowel and bladder. The patient is independent with bed mobility and eating. The patient fell in her bathroom and was able to activate Life Alert and obtained assistance. She also fell again and was sent to the emergency room (ER). The computed tomography (CT) scan was negative, and she was not admitted to the hospital. The patient was more recently admitted to the hospital and treated for pneumonia. She was subsequently discharged.
The patient's medical condition, functional ability and mobility are at the level as to require the requested consumer directed personal assistant services (CDPAS) services 24 hours/day, 7 days/week (live-in). She is frequently incontinent, has fallen in the bathroom along with recent falls and hospitalization, support an increase CDPAS services 12 hours/day, 7 days/week (total 84 hours/week). Given her recent hospitalization for pneumonia and likely self-sufficiency deterioration, an updated Uniform Assessment System (UAS) report may be indicated. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained by increasing CDPAS services to 24 hours/day, 7 days/week (live-in).
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.
The medical necessity for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in services is substantiated.
| 1 |
Diagnosis: Psoriatic Arthritis
Treatment: Xeljanz XR 11MG (milligrams)
The insurer denied the Xeljanz XR 11MG.
This patient is a female with history of psoriatic arthritis. The patient has previously tried and failed conventional disease modifying antirheumatic drug (DMARD) methotrexate, oral small molecule DMARD Otezla along with biologic DMARDs Stelara, Cosentyx and Tremfya. She has been recently treated with a trial of Xeljanz with good clinical results. The request for Xeljanz was initially denied due to policy
. The reason the provider is appealing the determination is because the patient has been doing well on Xeljanz monotherapy and has already tried and failed methotrexate due to transaminitis.
Yes, the proposed
is medically necessary.
The patient has psoriatic arthritis and has previously tried and failed multiple medications. The patient has been tried on Xeljanz monotherapy and overall has good clinical results. The patient has difficult to treat psoriatic arthritis as evidenced by the multiple failed conventional DMARDs and biologic DMARDs. Xeljanz was initially denied due to patient not combining Xeljanz with a conventional DMARD. She has already tried and failed methotrexate for conventional DMARD. Requiring the patient to add leflunomide (Arava) or sulfasalazine (Azulfidine)
|
Overturned
|
Medical necessity
|
Diagnosis: Psoriatic Arthritis
Treatment: Xeljanz XR 11MG (milligrams)
The insurer denied the Xeljanz XR 11MG.
The denial is overturned.
This patient is a female with history of psoriatic arthritis. The patient has previously tried and failed conventional disease modifying antirheumatic drug (DMARD) methotrexate, oral small molecule DMARD Otezla along with biologic DMARDs Stelara, Cosentyx and Tremfya. She has been recently treated with a trial of Xeljanz with good clinical results. The request for Xeljanz was initially denied due to policy not allowing coverage of the requested medication if it is not used in combination with a conventional DMARD such as methotrexate, leflunomide or sulfasalazine. The reason the provider is appealing the determination is because the patient has been doing well on Xeljanz monotherapy and has already tried and failed methotrexate due to transaminitis.
Yes, the proposed treatment is medically necessary.
The patient has psoriatic arthritis and has previously tried and failed multiple medications. The patient has been tried on Xeljanz monotherapy and overall has good clinical results. The patient has difficult to treat psoriatic arthritis as evidenced by the multiple failed conventional DMARDs and biologic DMARDs. Xeljanz was initially denied due to patient not combining Xeljanz with a conventional DMARD. She has already tried and failed methotrexate for conventional DMARD. Requiring the patient to add leflunomide (Arava) or sulfasalazine (Azulfidine) before Xeljanz is approved is not definitely going to improve patient outcomes. A conventional DMARD is not likely to control this patient's symptoms at this time given that she has already tried and failed so many biologic and targeted synthetic DMARDs. It will likely delay necessary treatment.
Xeljanz prescribing information states that is indicated for the treatment of adult patients with active psoriatic arthritis who have had an inadequate response or intolerance to methotrexate or other DMARDs. While the clinical trials done with Xeljanz in approval of this medication for treatment of psoriatic arthritis did combine it with a conventional DMARD, it was not studied as a secondary analysis whether this combination with a conventional DMARD was statistically significant in improving patient outcomes.
Since Xeljanz monotherapy has not been previously studied in psoriatic arthritis, a sub-study of OPAL Balance assessed Xeljanz 5 mg (milligrams) twice daily as monotherapy after methotrexate withdrawal versus with continued background methotrexate in patients with psoriatic arthritis. OPAL Balance is an open-label, long-term extension study of the drug in patients with psoriatic arthritis who had participated in the OPAL Broaden and OPAL Beyond phase 3 trials. This 12-month methotrexate withdrawal sub-study included 179 patients who had completed at least 24 months of Xeljanz treatment in OPAL Balance and were receiving oral methotrexate before sub-study entry. Patients remained on open-label Xeljanz 5 mg twice daily and were randomized to receive tofacitinib monotherapy or tofacitinib plus methotrexate for 12 months. Demographics and baseline characteristics were similar between the groups (mean age, 53.1/51.8 years; female, 52.2 percent/55.1 percent; mean disease duration, 11.3/11.2 years; low disease activity [Psoriatic Arthritis Disease Activity Score 3.2], 70 percent/62.9 percent). Primary endpoints were changes from sub-study baseline in Psoriatic Arthritis Disease Activity Score (PASDAS) and Help Assessment Questionnaire-Disability Index (HAQ-DI) at six months.
In general, efficacy and patient-reported outcomes were similar between treatment arms at month six and month 12. Rates of minimal disease activity were maintained regardless of methotrexate withdrawal. Rates of adverse events, serious adverse events, discontinuations due to adverse events, and adverse events of special interest were comparable between treatment arms; laboratory changes were also similar, except that elevations in liver function enzymes were more common with Xeljanz plus methotrexate. Of the patients receiving Xeljanz plus methotrexate, one met monitoring criteria for absolute neutrophil and two met monitoring criteria for absolute lymphocyte counts.
In general, no clinically meaningful differences in efficacy and safety were observed in patients with psoriatic arthritis who received open-label Xeljanz 5 mg twice daily as monotherapy after methotrexate withdrawal versus with continued methotrexate. No new safety risks were identified. Therefore the proposed treatment is medically necessary.
No. The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
While FDA (Food Drug Administration) approved prescribing information does suggest Xeljanz in combination with a conventional DMARD because that was how it was initially prescribed in the clinical studies, more recent studies such as the OPAL study as quoted above, does show that the addition of a conventional DMARD is not necessary in the treatment with Xeljanz for treatment of psoriatic arthritis and it doesn't necessarily add benefit for the patient and may just add more risk with potential side effects. This patient has been doing well currently on monotherapy and therefore should be allowed to continue on monotherapy. Therefore the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
| 1 |
Diagnosis: Weakness on The Right Side of Body, Numbness Along The Head, Chest Pain, Dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
patient is a male with a history of stroke. He presented to the emergency ward with the complaint of dizziness, right-sided weakness and paresthesia for four days.
At presentation, the patient had a normal neurological examination documented. CT (computed tomography) brain was negative for acute intracranial pathology. He was admitted to the acute inpatient service for suspected stroke. Subsequent MRI (magnetic resonance imaging) brain was negative. He was discharged.
.
The patient presented with a four day history of neurological symptoms. He was not a candidate for acute stroke intervention (Powers et al.). The emergency ward provider documented the patient had a normal neurological examination and negative CT (computed tomography) brain.
|
Upheld
|
Medical necessity
|
Diagnosis: Weakness on The Right Side of Body, Numbness Along The Head, Chest Pain, Dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The denial is upheld
The patient is a male with a history of stroke. He presented to the emergency ward with the complaint of dizziness, right-sided weakness and paresthesia for four days.
At presentation, the patient had a normal neurological examination documented. CT (computed tomography) brain was negative for acute intracranial pathology. He was admitted to the acute inpatient service for suspected stroke. Subsequent MRI (magnetic resonance imaging) brain was negative. He was discharged.
No, the Inpatient admission was not medically necessary.
The patient presented with a four day history of neurological symptoms. He was not a candidate for acute stroke intervention (Powers et al.). The emergency ward provider documented the patient had a normal neurological examination and negative CT (computed tomography) brain. Based on this, the likelihood of stroke was low, and his condition was incompatible with transient ischemic attack given the duration of symptoms (Mendelson et al.). The neurological evaluation, monitoring, diagnostic studies and treatment could have been safely and effectively provided at a lower level of care.
Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
| 1 |
Diagnosis: Prostate Cancer.
Treatment: OncotypeDX Prostate Test (0047U).
The insurer denied the OncotypeDX Prostate Test (0047U).
.
The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 1 of 20 cores. The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate-specific antigen) was
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Upheld
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Medical necessity
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Diagnosis: Prostate Cancer.
Treatment: OncotypeDX Prostate Test (0047U).
The insurer denied the OncotypeDX Prostate Test (0047U).
The denial is upheld.
The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 1 of 20 cores. The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate-specific antigen) was <10.
No, the OncotypeDX Prostate Test (0047U) was not medically necessary.
The patient has a low-risk prostate cancer.
Per AUA Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"[ref #2]
Guideline Statement 32[ref #2]
Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)[ref #2]
Therefore, given the above, the OncotypeDX Prostate Test (0047U) was not medically necessary. The health plan's denial was consistent with generally accepted guidelines and practice.
| 1 |
The Endovenous Ablation Therapy was medically necessary.
The patient underwent Venaseal closure to treat axial vein reflux. The procedure was denied coverage by the health plan on the basis that the cyanoacrylate embolization is unproven.
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Overturned
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Medical necessity
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Diagnosis: Varicose Veins
Treatment: Endovenous Ablation Therapy
The insurer denied: Endovenous Ablation Therapy
The denial is overturned
The patient is an elderly female. The patient underwent Venaseal closure to treat axial vein reflux. The procedure was denied coverage by the health plan on the basis that the cyanoacrylate embolization is unproven. The denial is being appealed.
The Endovenous Ablation Therapy was medically necessary.
The patient underwent Venaseal closure to treat axial vein reflux. The procedure was denied coverage by the health plan on the basis that the cyanoacrylate embolization is unproven.
The sole reason for denial of coverage was that the effectiveness of cyanoacrylate embolization (CAE) is unproven. Therefore, the data on the efficacy of the procedure will be addressed.
Treatment of saphenous incompetence is currently performed by different interventionist alternatives, which include surgical, endothermal, and nonthermal ablation therapies. In the last 15 years, two endothermal therapies, namely, endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), were developed as new standard procedures. The guidelines of the European Society for Vascular Surgery, the American Venous Forum, and the United Kingdom's National Institute for Health and Care Excellence recommend endovenous thermal treatment as the first-choice therapy for this condition. However, endothermal therapies have side-effects linked to thermal energy that damages the venous wall and causes pain, skin burns, skin pigmentation, nerve damage, and even the formation of arteriovenous fistula. Tumescent anesthesia is mandatory to prevent thermal damage to surrounding tissues and to avoid causing pain to the patient.
To avoid some of these unwelcome effects, non-thermal, non-tumescent endovenous ablation techniques have recently emerged, including mechanochemical endovenous ablation, ultrasound-guided foam sclerotherapy, and cyanoacrylate ablation (CAE).
CAE (cyanoacrylate ablation) has been analyzed in multiple recent studies, including three comparative studies and two randomized controlled trials [2-4]. All these studies demonstrate that CAE (cyanoacrylate ablation) is safe and effective in achieving saphenous vein closure. The randomized studies demonstrate that CAE's (cyanoacrylate ablation's) efficacy is equivalent to thermal ablation and that adverse outcomes may be lower with CAE (cyanoacrylate ablation).
A recent systematic review [1] concluded that "Compared with EVLA [endovenous laser ablation] and RFA [radiofrequency ablation], CA [cyanoacrylate ablation] treatments yield comparable effectiveness outcomes and lead to less frequent and fewer mild adverse events, without difference in major adverse events. Furthermore, CA [cyanoacrylate ablation] devices have advantages in terms of quality of care indicators, such as pain during intervention, treatment and recovery times, lower use of anesthesia, and zero use of compression bandages after treatment."
Based on the above discussion, it is concluded that CAE (cyanoacrylate ablation) has been proven to be at least as safe and effective as traditional ablation techniques such as RFA (radiofrequency ablation) and EVLA (endovenous laser ablation) CAE (cyanoacrylate ablation) should not be considered unproven.
The procedure was medically necessary, because the patient met well accepted criteria for axial vein closure. Specifically, the patient had symptoms significant enough to adversely affect normal function, she had failed a trial of compression therapy, she had duplex-proven reflux affecting the treated vein, and the technique used (cyanoacrylate ablation) has been proven to be at least as safe and effective as traditional ablation methods (as per discussion above).
| 1 |
Diagnosis: Malocclusion
Treatment: braces and monthly visits
The insurer denied coverage for braces and monthly visits
The
review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report as required and has chosen the
qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and
of the gingival margin are present, to support orthodontic necessity. The insurer has denied coverage for orthodontic
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Upheld
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Medical necessity
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Diagnosis: Malocclusion
Treatment: braces and monthly visits
The insurer denied coverage for braces and monthly visits
The denial is upheld
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 23 points on review by internal reviewers.
Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.
In this case, the treating orthodontist claims an automatic qualifying condition of
cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.
Based on the above, the insurer's denial must be upheld. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. The medical necessity for braces and monthly visits services is not substantiated.
| 1 |
Diagnosis: Confusion, dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The patient is a female with a history of alcohol use disorder and polysubstance use disorder. She was admitted after presenting with complaint of confusion, dizziness and awakening on the floor.
On presentation, the patient's vital signs were normal, neurological examination was normal and CT (computed tomography) brain was negative. She was admitted for suspected seizure. She had EEG (electroencephalogram) and MRI (magnetic resonance imaging) that were negative for significant abnormality. She had no recurrent events and was discharged without an anticonvulsant.
.
The member was suspected of having a single seizure. At presentation she was at her baseline neurological status.
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Upheld
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Medical necessity
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Diagnosis: Confusion, dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.
The patient is a female with a history of alcohol use disorder and polysubstance use disorder. She was admitted after presenting with complaint of confusion, dizziness and awakening on the floor.
On presentation, the patient's vital signs were normal, neurological examination was normal and CT (computed tomography) brain was negative. She was admitted for suspected seizure. She had EEG (electroencephalogram) and MRI (magnetic resonance imaging) that were negative for significant abnormality. She had no recurrent events and was discharged without an anticonvulsant.
No, the Inpatient admission was not medically necessary.
The member was suspected of having a single seizure. At presentation she was at her baseline neurological status. There were no recurrent events and diagnostic studies were negative for acute pathology. The neurological assessment, monitoring, treatment and diagnostic studies could have been safely and effectively provided at a lower level of care (Shellhaas; Foster et al.).
Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
| 1 |
Diagnosis: Lower extremity wounds
Treatment: Skilled nursing visits
The insurer denied skilled nursing visits.
The patient is a female with past medical history of idiopathic chronic venous hypertension right lower extremity ulceration according to records who also had a history of lymphedema with lymphedema pumps at home and obesity. The patient was receiving daily visiting nurse services to treat right lower extremity ulcers/wounds. The patient is home bound due to difficulty and taxing effort to leave home requiring a cane and 1-2 person assist.
Skilled Nursing Visits x 14 are medically necessary for this patient.
There is documentation of diagnoses of lymphedema and chronic venous hypertension with leg ulcers. The wound care nurse from visiting nurse services recommended treatment with iodoform packing. It was recommended to continue this regimen daily. The insurer denied coverage on the basis that patient's wounds were small; however, there is documentation of one of the ulcers 0.8 cm of depth by 6 cm of the length and the other 0.5 cm of depth by 5 cm in length. In fact, the notes indicate the #1 wound actually increased in size. The insurance
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Overturned
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Medical necessity
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Diagnosis: Lower extremity wounds
Treatment: Skilled nursing visits
The insurer denied skilled nursing visits.
The health plan's determination is overturned.
The patient is a female with past medical history of idiopathic chronic venous hypertension right lower extremity ulceration according to records who also had a history of lymphedema with lymphedema pumps at home and obesity. The patient was receiving daily visiting nurse services to treat right lower extremity ulcers/wounds. The patient is home bound due to difficulty and taxing effort to leave home requiring a cane and 1-2 person assist.
Skilled Nursing Visits x 14 are medically necessary for this patient.
There is documentation of diagnoses of lymphedema and chronic venous hypertension with leg ulcers. The wound care nurse from visiting nurse services recommended treatment with iodoform packing. It was recommended to continue this regimen daily. The insurer denied coverage on the basis that patient's wounds were small; however, there is documentation of one of the ulcers 0.8 cm of depth by 6 cm of the length and the other 0.5 cm of depth by 5 cm in length. In fact, the notes indicate the #1 wound actually increased in size. The insurance denial also stated the patient's wounds were not complex and did not require the specialized skill set of a nurse, but in fact these wounds were large and complex requiring packing with iodoform which is a skill set of a nurse. The insurer also stated the patient could learn to treat her wounds or a caregiver could be taught how to take care of her wounds. This was not feasible for the patient herself due to her morbid obesity and mobility issues and the patient's caregiver was not willing to perform wound care. It is not appropriate for denial of services based on a caregivers inability to provide complex wound care. In addition, the insurer stated the wound care could be performed by a different provider such as LPN (licensed practical nurse) or HHA (home health aide) but in New York state, this is out of their scope of practice. Literature from Up-to-Date states" wound packing is considered basic standard care Packing wounds associated with significant dead space or undermining is important to reduce physiological dead space, absorb exudate/seroma collection, and reduce the potential for infection. Packing can also be an effective temporary dressing technique between planned serial debridements".
| 1 |
Diagnosis: Substance abuse
Treatment: Inpatient detoxification
The insurer denied coverage for inpatient detoxification
The
This patient was admitted to an inpatient hospital detoxification treatment. He reportedly had withdrawal symptoms including tremors, sweats, chills, nausea and vomiting, agitation, anxiety, and he had a clinical institute withdrawal assessment for alcohol (CIWA) score of 15. He reportedly had multiple inpatient detoxification treatments (at least 12 reported) and inpatient rehabilitation treatments and still was unable to stop his large amount of daily alcohol use and cocaine use. He reportedly had hepatitis C, hypertension, asthma, osteoarthritis, and back pain.
In this case this patient had been drinking large amounts of alcohol daily including two to six packs of beer per day and cocaine/crack daily and was at risk for severe, complicated, and life-t
alcohol use, so he required 24-hour inpatient hospital detoxification treatment as he was at risk medically.
he continued to use large amounts of alcohol daily despite multiple
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Overturned
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Medical necessity
|
Diagnosis: Substance abuse
Treatment: Inpatient detoxification
The insurer denied coverage for inpatient detoxification
The denial is overturned
This patient was admitted to an inpatient hospital detoxification treatment. He reportedly had withdrawal symptoms including tremors, sweats, chills, nausea and vomiting, agitation, anxiety, and he had a clinical institute withdrawal assessment for alcohol (CIWA) score of 15. He reportedly had multiple inpatient detoxification treatments (at least 12 reported) and inpatient rehabilitation treatments and still was unable to stop his large amount of daily alcohol use and cocaine use. He reportedly had hepatitis C, hypertension, asthma, osteoarthritis, and back pain.
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient had been drinking large amounts of alcohol daily including two to six packs of beer per day and cocaine/crack daily and was at risk for severe, complicated, and life-threatening withdrawal due to this large amount of daily alcohol use, so he required 24-hour inpatient hospital detoxification treatment as he was at risk medically. According to The Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use large amounts of alcohol daily despite multiple past inpatient detoxification treatments and rehabilitation treatments and he required and took detoxification medication, Librium, to modify and treat withdrawal. He needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life-threatening withdrawal symptoms. It was reported that he had detoxification medication, Librium throughout his stay. He also had comorbid bipolar disorder with a past psychiatric hospitalization and 2 past suicide attempts which put him at further risk of harm to self. He reportedly lacked supports and was living by himself and was unemployed, lacked coping skills for abstinence and lack relapse prevention skills. He could not maintain abstinence so he could not safely and effectively be treated in a less restrictive level of care then. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this medical inpatient detoxification setting. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance/alcohol detoxification. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient.
The insurer's denial of coverage for the hospital based inpatient detoxification admission is overturned. Medical Necessity is substantiated.
| 1 |
Diagnosis: Crohn's Disease
Treatment: Stelara
The insurer denied Stelara.
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Overturned
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Experimental/Investigational
|
Diagnosis: Crohn's Disease
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is overturned.
The patient is a male with Crohn's disease.
Yes, Stelara every 4 weeks in this case is supported by current medical literature and is likely to be more beneficial for this patient. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's Disease, as this patient has. In this case, the patient has failed Stelara every 8 weeks; continuation of dosing every 8 weeks may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient. For all of these reasons, Stelara 90 mg every 4 weeks is supported as likely to be more beneficial than any standard treatment for the treatment of Crohn's disease in this case.
| 1 |
Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Adm
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Overturned
|
Medical necessity
|
Diagnosis: Asthma
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned
The patient is an adult male who has a history of asthma and hypertension. The patient's hospital stay was approved only at an "Observation" level, but not at an "Inpatient" level. According to correspondence from the Provider, the patient is an adult male with a past medical history of asthma and hypertension who presented to the Emergency Room with a cough productive of whitish sputum, wheezing and shortness of breath of three days duration that was not relieved with albuterol at home. He stated that the symptoms were typical of his usual asthma exacerbation. He reported that he had also just completed a ten-day tapering course of prednisone prescribed by his Primary Care Physician with no improvement. The patient's presenting vital signs were significant for hypertension, tachycardia and hypoxia. Blood pressure was 177/105, heart rate was 110 beats per minute, respiratory rate was 20 breaths per minutes, and temperature was 97.6 Fahrenheit, with an oxygen saturation of 94% (percent). The patient's presenting physical examination revealed an increased work of breathing and wheezing. His initial laboratory testing revealed an elevated glucose level of 186 milligrams per deciliter (mg/dL). The pro-brain natriuretic peptide (BNP) was elevated at 182 picograms per milliliter (pg/mL). COVID-19 (coronavirus disease 2019) testing was negative. The chest x-ray showed increased opacities at the lung apices and increased lucency of the left lung, both present previously. A computed tomography angiogram of the chest was performed to assess for pulmonary embolism with none identified. There was mild bilateral bronchial wall thickening suggestive of bronchitis.
In the emergency room, the patient was placed on a cardiac monitor and on continuous pulse oximetry. He received solumedrol 125 milligrams intravenous piggyback (IVPB) once, ipratropium-albuterol (Duonebs) every 20 minutes for three doses and magnesium sulfate two grams intravenous piggyback once to treat the acute exacerbation of asthma.
The proposed inpatient hospital admission was medically necessary.
The patient had a history of asthma and had failed both outpatient treatment and in-hospital observation treatment for status asthmaticus before being admitted as an inpatient for several days for further treatment and monitoring.
In the Observation Unit, the patient supplemental oxygen via nasal cannula or aerosol mask, Solu-Medrol 40 milligrams intravenous piggyback every eight hours and ipratropium-albuterol every four hours to treat the acute exacerbation of asthma. He received azithromycin 500 milligrams by mouth to treat the likely concomitant bronchitis. He received Norvasc five milligrams by mouth daily for hypertension, which represented an increased dose compared to his usual 2.5 milligram daily dose. He received Lovenox 40 milligrams subcutaneously daily for deep vein thrombosis prophylaxis. The patient reported minimal improvement of his symptoms with Duonebs. The decision was made to admit him to the inpatient unit as he had failed this trial of management in the Observation Unit. When seen by the admitting Attending Physician, the patient had persistent diffuse inspiratory and expiratory wheezing. On the inpatient unit, the patient received oxygen at two to three liters per minute via nasal cannula. He received solumedrol 40 milligrams intravenous piggyback every eight hours and ipratropium-albuterol via nebulizer every four hours to treat the asthma exacerbation. He received Symbicort two puffs two times daily as a controller medication. He received azithromycin 250 milligrams by mouth daily to treat the concomitant bronchitis. Montelukast ten milligrams by mouth nightly was added on Day #4. By the day of discharge, the patient's symptoms had subsided, and he was able to be weaned off supplemental oxygen. His oxygen saturation improved to 97%. He was deemed to be stable for discharge.
| 1 |
Diagnosis: Radial styloid tenosynovitis
Treatment: L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated, off the shelf, any type
The insurer denied coverage for L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated, off the shelf,
This is a male with right wrist pain and diagnosed with radial styloid tenosynovitis. He was seen for physical therapy and provided an L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated.
According to the case notes, the insurer denied coverage for the requested orthosis due to lack of medical records including a detailing a history and physical examination.
A physical therapy note documents the patient's right wrist pain and difficulty performing activities of daily living. Another physical therapy note again documents his right wrist impairment, as well as detailed right upper extremity range of
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Overturned
|
Medical necessity
|
Diagnosis: Radial styloid tenosynovitis
Treatment: L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated, off the shelf, any type
The insurer denied coverage for L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated, off the shelf, any type
The denial is overturned
This is a male with right wrist pain and diagnosed with radial styloid tenosynovitis. He was seen for physical therapy and provided an L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated.
According to the case notes, the insurer denied coverage for the requested orthosis due to lack of medical records including a detailing a history and physical examination. However, the therapy notes submitted for review are sufficient to support the medical necessity of the requested orthosis. A physical therapy note documents the patient's right wrist pain and difficulty performing activities of daily living. Another physical therapy note again documents his right wrist impairment, as well as detailed right upper extremity range of motion/manual muscle testing and response to treatment. From a physical medicine & rehabilitation/pain management perspective, the submitted physical therapy notes appropriately document the patient's right wrist/hand impairment and support the medical necessity of the right wrist orthosis.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for L3809-RT-KX, wrist hand finger orthosis, without joints, prefabricated, off the shelf, any type is overturned. Medical Necessity is substantiated.
| 1 |
Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's disease
Treatment: Home Health Care/consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts
The health plan denied the requested consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts as not medically necessary.
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Overturned
|
Medical necessity
|
Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's disease
Treatment: Home Health Care/consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts
The health plan denied the requested consumer direct personal aide service (CDPAS) 7 days x 12 hours x 2 shifts as not medically necessary.
The health plan's determination is overturned.
The patient is a male with past medical history of Alzheimer's disease, lumbar spinal stenosis, hypertension, urinary incontinence, chronic renal insufficiency, anxiety and osteoarthritis who had a mutual case with his wife for consumer directed personal aide (CDPAS) services who was approved for 24 hours/day, 7 days/week, live -in following Uniform Assessment System (UAS). The patient had multiple falls, most occurring in the overnight hours when he attempted to use the bathroom overnight. There was a request to increase CDPAS services and the patient's primary care physician (PCP) completed form 4359 following an office visit. Notes from insurer noted the daughter reported the patient went to bathroom every 3 hours and refused to use durable medical equipment due to dementia. The patient had a UAS performed via video assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of phone use and transportation. With tasks of managing medication, stairs, and equipment management the patient was assessed at extensive assistance while limited assistance with tasks of bathing, dressing lower body, and toilet use. The patient was assessed at supervision with the task of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and eating while independent with task of bed mobility. The patient had a follow-up visit with his PCP and neurology, noting the patient had ongoing cognitive decline and was referred to physical therapy. The insurer sent a notification that review was extended due to lack of overnight sleep study. Overnight care logs noted the patient had incontinence care at least every three hours. The patient's PCP provided a letter stating the patient's medical diagnoses, noting the patient gets up in the middle of the night and without assistance he is likely to be injured. The provider recommended to 12-hour shifts for personal care assistant (PCA) services. The patient's PCP sent another letter stating the patient was at times incontinent and needed changing during the night hours to prevent pressure ulcers. The provider also noted the patient had generalized weakness and required repositioning frequently during the night and that his Alzheimer's disease sometimes prevented the patient from sleeping at night.
The health plan's determination of medical necessity is overturned, in whole.
Yes, There is documentation from the patient's PCP and neurologist of worsening physical and cognitive functioning. There is documentation from the patient's PCP of the medical necessity of increasing PCA services to include overnight care. Overnight care logs document the patient has assistance needs with activities of daily living (ADLs) at least every 3 hours which would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient's care needs cannot be met with adaptive equipment and medical supplies alone. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 7 days x 12 hours x 2 shifts are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
| 1 |
Diagnosis: Seizure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
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Upheld
|
Medical necessity
|
Diagnosis: Seizure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.
The patient has a past medical history significant for a headache, who was brought in by her mother for a new onset seizure. The patient was in her usual state of health until the day of admission when her mother tried to wake her up. She woke up, was responsive, and went back to sleep again. After 2 minutes, her sister went into the room to wake her and she found her seizing. She was extending both of her upper and lower extremities with flexion of both hands and feet, biting her tongue and drooling of saliva and blood. She had no rolling of her eyes but she was staring and not responsive. This episode lasted 2-3 minutes. There was no urinary or fecal incontinence. After that, she was confused, complained of back and neck pain and did not remember anything. Otherwise, there were no similar episodes before, no fever, no travel, no trauma, no sick contacts.
She was brought to the emergency room (ER) and the initial vital signs were a temperature of 36.7 degrees Fahrenheit, heart rate (HR) 120, respiratory rate (RR) 18, oxygen saturation (O2 sat) 97%, and blood pressure (BP) 137/82. She had Glasgow Coma Scale (GCS) of 15 and was described as alert, oriented to person, place and time. Laboratory studies were done and were unremarkable. She was admitted to the pediatric floor with a diagnosis of new onset seizure. The plan was for seizure precautions, neurological checks every (q) 4 hours, electrocardiogram (EKG), Ativan as needed (PRN) and a neurology consult. The neurologist recommended magnetic resonance imaging (MRI) of the head without contrast and a video electroencephalogram (EEG). The patient was monitored and a thorough assessment for the etiology of the seizure was performed. She had a head computed tomography (CT) scan, magnetic resonance imaging (MRI), complete blood count (CBC), creatine kinase (CK), comprehensive metabolic panel (CMP), magnesium (Mg) levels and urine drug screening (UDS), all of which were unremarkable. The head CT scan and MRI of the brain were unremarkable. 36 hours of video EEG showed occasional bursts of irregular generalized spike and wave complexes lasting up to one second seen more frequently during wakefulness than sleep. After the first dose of Keppra, the video electroencephalogram (VEEG) showed much less frequent epileptic discharges overnight. The patient was very anxious and scored 15 on a general anxiety disorder (GAD) questionnaire. Psychiatry was consulted and they recommended follow up in their outpatient clinic. The discharge diagnosis was primary generalized epilepsy. The patient was deemed medically stable and discharged on Keppra 250 milligrams (mg) q 12 hours and with seizure precautions. She was given instructions to follow up with the primary medical doctor (PMD), neurologist and ophthalmologist as an outpatient.
At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was not medically necessary for this patient.
This patient presented with an isolated episode of seizure activity. Upon admission she had no focal neurological findings, unremarkable laboratory values and a negative head CT scan. The plan at admission was for pediatric neurology consultation and an EEG. While admitted, she did not require any complex or highly technical skilled care. She had a video EEG which did show some positive findings that improved on repeat EEG after starting antiepileptic medication. An MRI of the brain was also done and returned normal. She was observed and had no recurrence of symptoms. Information available to the emergency room (ER) physician at the time of admission documented an alert and oriented patient with normal vital signs, normal laboratory values and a normal head CT scan. These findings would not meet criteria for admission to an inpatient level of care. If at the time of admission, she did not demonstrate altered mental status, new focal neurological deficit, metabolic derangement, recurrent seizure, intracranial process such as bleeding or increased intracranial pressure, admission to inpatient level of care was not medically necessary.
The provided information referenced Milliman Care Guidelines (MCG) Health Pediatric Seizure criteria. Inpatient admission would be indicated for complex febrile seizure, status epilepticus or repetitive seizure not controlled with emergent treatment, brain disorder that requires monitoring or intervention, brain insult like severe trauma, stroke, drug toxicity or withdrawal, or if altered mental status that is severe or persistent, new focal neurological deficit that is severe or persistent, metabolic disorder (i.e. hypoglycemia or hyponatremia) that is severe or persistent, recurrent seizure, outpatient anti-seizure regimen cannot be established (patient cannot tolerate medication or initiation requires inpatient care), need for ongoing IV infusion of anti-seizure medication, central bleeding, hydrocephalus or vasospasm monitoring, increased intracranial pressure or cerebral edema monitoring. Other condition treatment or requiring inpatient admission. InterQual guidelines were also referenced and state inpatient admission required for change in seizure pattern, multiple episodes in 24 hours, sodium between 120-126 or new onset focal finding. The patient did not meet any of these criteria.
| 1 |
Diagnosis: Upper gastrointestinal bleeding
Treatment: Sequential or periodic EGD (esophagogastroduodenoscopy), procedure code 43239.
The insurer denied coverage for sequential or periodic EGD, procedure code 43239.
.
The patient had a history of gastroesophageal reflux disease (GERD) with erosions and gastritis with Helicobacter Pylori. She was taking Omeprazole and Carafate. She was having black tarry stool. An endoscopy revealed gastritis and duodenitis.
blood in the stool with a history of dyspepsia, gastrointestinal reflux disease associated with GI bleeding, and dyspepsia with a poor response to medical therapy.
The submitted medical record states that the patient had abdominal pain and black tarry stools. A previous endoscopy showed erosive esophagitis. The black stools suggest that she was having upper GI bleeding. The patient had dyspepsia with a history of GI bleeding, a poor response to medical therapy, and a history of esophagitis with erosions.
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Overturned
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Medical necessity
|
Diagnosis: Upper gastrointestinal bleeding
Treatment: Sequential or periodic EGD (esophagogastroduodenoscopy), procedure code 43239.
The insurer denied coverage for sequential or periodic EGD, procedure code 43239.
The denial is overturned.
The patient had a history of gastroesophageal reflux disease (GERD) with erosions and gastritis with Helicobacter Pylori. She was taking Omeprazole and Carafate. She was having black tarry stool. An endoscopy revealed gastritis and duodenitis.
Milliman Care Guideline (MCG) guideline ACG: A-0203 lists indications for upper gastrointestinal (GI) endoscopy. These indications include having gastrointestinal bleeding such as blood in the stool with a history of dyspepsia, gastrointestinal reflux disease associated with GI bleeding, and dyspepsia with a poor response to medical therapy.
The submitted medical record states that the patient had abdominal pain and black tarry stools. A previous endoscopy showed erosive esophagitis. The black stools suggest that she was having upper GI bleeding. The patient had dyspepsia with a history of GI bleeding, a poor response to medical therapy, and a history of esophagitis with erosions. These criteria met MCG guidelines for Upper GI endoscopy.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for sequential or periodic EGD (esophagogastroduodenoscopy), procedure code 43239 is overturned. Medical Necessity is substantiated.
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Diagnosis: Hyponatremia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
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Overturned
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Medical necessity
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Diagnosis: Hyponatremia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.
This is a patient with a history of hypertension (HTN), mitral valve prolapse, and myomectomy who presented to the hospital with diarrhea after taking Amoxicillin for 6 days and nausea and vomiting for 2 days. She reported liquid, non-bloody stools with a foul odor and epigastric pain. She also reported a decreased appetite, feeling weak, off balance and periods of confusion. She denied fevers, chills, chest pain, shortness of breath, lightheadedness or a cough. Her lab results showed a sodium of 121, a potassium of 3.3 and a carbon dioxide (CO2) of 30.2. She was given 2 liters (L) of normal saline and oral potassium in the emergency room. A repeat sodium was 132 with a potassium of 3.4. A computed tomography (CT) scan of her abdomen and pelvis did not show any acute abnormalities. Nephrology was consulted for hyponatremia which they felt was secondary to hydrochlorothiazide (HCTZ) use in the setting of diarrhea. There was concern for her sodium over-correcting and the intravenous (IV) fluids were stopped with the recommendation for a repeat sodium at 2 PM, 8 PM and in the morning. The goal sodium correction was 4-6 milliequivalents (meq) within the first 24 hours. The next sodium level was 135 so she was given dextrose 5 percent in water (D5W) 250 cubic centimeters (cc) over one hour, Desmopressin (DDAVP) and placed on a fluid restriction. The sodium (Na) was 132 and she was given another 250 cc of D5W with a fall of the Na to 130. The Na was 132 and she was considered stable for discharge with lab and primary care physician (or provider) (PCP) follow up. At issue is the medical necessity of an inpatient stay.
The inpatient stay was medically necessary based on the documentation provided. The patient presented with severe, symptomatic hyponatremia with a sodium of 121millieqivalents per liter (meq/L). Her sodium was then rapidly corrected to 132 meq/L within the same day as her presentation. She needed inpatient management to monitor her serum sodium concentration and safely bring it down and prevent further increases. Rapid correction of hyponatremia (greater than 6-8 meq/L with the first 24 hours) can lead to life-threatening central pontine myelinolysis. An inpatient admission was necessary to closely manage and monitor her serum sodium.
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Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
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Overturned
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Medical necessity
|
Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.
This is a female with a history of vocal cord paralysis and hemihypertrophy who had been sick for three days with a fever and a cough. She developed difficulty breathing and a decrease in her oral intake of liquids. Her mother was concerned about her rapid rate of breathing and persistent fever, so she decided to take her to the emergency room (ER) for treatment.
In the ER she was noted to be dehydrated and she was given 2 intravenous (IV) boluses of normal saline. Her pulse oximeter reading was 93% (percent) and she was started on oxygen supplementation. On physical exam she was febrile to 103 degrees and was noted to have intercostal retractions, wheezing on the right lung and rhonchi bilaterally. She was treated with 3 doses of albuterol with no improvement in her increased work of breathing and abdominal retractions. A chest x-ray was normal. A respiratory viral panel was positive for RSV (Respiratory syncytial virus) and enterovirus. Her venous blood gas was abnormal with a pH (potential for hydrogen) of 7.33 and a pCO2 (partial pressure of carbon dioxide) of 40. Her lactic acid level was elevated at 5.2 demonstrating evidence of metabolic acidosis. Her urine specific gravity was high at 1030 confirming dehydration. Despite treatment with oxygen, she continued to have hypoxemia and increased work of breathing and she was switched to high flow oxygen at 20 liters per minute with an FIO2 (fraction of inspired oxygen) of 40%. Upon repeat examination after treatment in the ER, she was noted to have a persistent increased work of breathing with abdominal retractions, wheezing on the left lung and rhonchi bilaterally. The decision was made to admit the child to the PICU (pediatric intensive care unit) with a diagnosis of bronchiolitis and dehydration for continued treatment with IV fluids, albuterol treatments and high flow oxygen.
The insurer has denied the inpatient hospital admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.
The patient was treated appropriately in the ER for hypoxemia and clinical and lab evidence of dehydration. She was treated with two IV boluses of normal saline, 3 treatments with nebulized albuterol and high flow oxygen at 40% but continued to have an increased work of breathing and rhonchi and wheezing upon chest examination. When she did not respond to treatment in the ER, it was appropriate and consistent with the standard of care to admit the infant to the PICU with a diagnosis of bronchiolitis for ongoing oxygen supplementation and IV fluids. She was not stable enough to be safely discharged.
The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
The insurer's denial of coverage for inpatient hospital admission is overturned. Medical necessity is substantiated.
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Diagnosis: Crohn's
Treatment: Humira
The insurer denied Humira 40 milligrams (mg) every week.
This female patient has severe ileocolonic Crohn's disease and has had prior bowel resection following a bowel perforation. She was started on Humira at standard dosing but had a recent hospitalization for a flare of her Crohn's disease.
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Overturned
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Medical necessity
|
Diagnosis: Crohn's
Treatment: Humira
The insurer denied Humira 40 milligrams (mg) every week.
The health plan's determination is overturned.
This female patient has severe ileocolonic Crohn's disease and has had prior bowel resection following a bowel perforation. She was started on Humira at standard dosing but had a recent hospitalization for a flare of her Crohn's disease.
Humira Pen is medically necessary for this patient. Dose escalation is the standard of care in patients with inflammatory bowel disease (IBD) who are on a biological medication and not responding to standard dose of the medication. Dose escalation in biological therapy used to treat inflammatory bowel disease is a well accepted practice and supported by literature in patients who are not responding to standard dosing of the medication. Therefore, Humira dose escalation to weekly in this patient who failed standard dosing of Humira is appropriate and medically necessary.
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Diagnosis: Orthopedic/Musculoskeletal
Treatment: Surgical Services - Intracept procedure
The insurer denied Intracept procedure as experimental/investigational.
The patient is a female with complaints of low back pain. The magnetic resonance imaging (MRI) scan of the lumbar spine demonstrated degenerative disc disease and degenerative endplate changes predominantly involving the lumbar (L) 5- sacral (S) 1 levels. The patient is noted to have ongoing low back pain following interlaminar epidural injection. Her pain is rated an 8 out of 10. She has trialed multiple medications, and currently utilizes ibuprofen. The physical exam demonstrated positive tenderness to palpation over lumbar erector spinae with persistent muscle spasms and trigger points. There was a recommendation for the Intracept procedure by her provider.
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Upheld
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Experimental/Investigational
|
Diagnosis: Orthopedic/Musculoskeletal
Treatment: Surgical Services - Intracept procedure
The insurer denied Intracept procedure as experimental/investigational.
The denial is upheld.
The patient is a female with complaints of low back pain. The magnetic resonance imaging (MRI) scan of the lumbar spine demonstrated degenerative disc disease and degenerative endplate changes predominantly involving the lumbar (L) 5- sacral (S) 1 levels. The patient is noted to have ongoing low back pain following interlaminar epidural injection. Her pain is rated an 8 out of 10. She has trialed multiple medications, and currently utilizes ibuprofen. The physical exam demonstrated positive tenderness to palpation over lumbar erector spinae with persistent muscle spasms and trigger points. There was a recommendation for the Intracept procedure by her provider.
At issue is whether the proposed health service or treatment Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
This patient has complaints of low back pain. There is a request for Intracept procedure or intraosseous basivertebral nerve ablation. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A United States Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is a lack of substantial support for this procedure, and it is currently not considered the standard of care.
Given this, the proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
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Diagnosis: Newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis.
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
This patient is an elderly female who has medical conditions including newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis. She is appealing denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift. The health plan approved 40 hours per week.
Uniform Assessment System (UAS) evaluation recently completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistance with personal hygiene, upper body dressing, toilet use, and bed mobility; limited assistance with managing finances and medications; and independent with eating. She has bowel and bladder incontinence. Compared to Uniform
System (UAS) evaluation completed last year, there has been a decline with managing medications, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility.
Appeal statements note the patient's condition has worsened since her diagnosis of advanced ovarian cancer. Chemotherapy has resulted in diarrhea and fecal incontinence with numerous unexpected trips to the toilet day and night. The patient reports that she lives alone and has cancer, weakness, and difficulty walking. She
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Overturned
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Medical necessity
|
Diagnosis: Newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis.
Treatment: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied: Increase Personal Care Aide (PCA) Services for a Total Amount of 168 Hours per Week (Split Shift)
The denial is partially overturned
This patient is an elderly female who has medical conditions including newly diagnosed ovarian cancer, osteoarthritis, diabetes, asthma, hypertension, and osteoporosis. She is appealing denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift. The health plan approved 40 hours per week.
Uniform Assessment System (UAS) evaluation recently completed shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistance with personal hygiene, upper body dressing, toilet use, and bed mobility; limited assistance with managing finances and medications; and independent with eating. She has bowel and bladder incontinence. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with managing medications, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility.
Appeal statements note the patient's condition has worsened since her diagnosis of advanced ovarian cancer. Chemotherapy has resulted in diarrhea and fecal incontinence with numerous unexpected trips to the toilet day and night. The patient reports that she lives alone and has cancer, weakness, and difficulty walking. She states she needs assistance with everything.
The requested increase in personal care aide (PCA) services for a total amount of 168 hours per week, live in, is medically necessary in part. However, in part as an increase in personal care aide services for a total amount of 168 hours per week, split shift is not medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.
This patient has multiple chronic conditions including recently diagnosed ovarian cancer for which she is receiving chemotherapy. She is appealing denial of increase personal care aide (PCA) services for a total amount of 168 hours per week, split shift. The health plan approved 40 hours per week. Uniform Assessment System (UAS) evaluation recently completed shows the patient requires assistance with all activities of daily living (ADLs). The patient is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed last year, there has been a decline with managing medications, bathing, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. The records and appeal statements note the patient's functional status has declined since being diagnosed with ovarian cancer. She has fecal urgency and incontinence. The information provided shows that this patient has significant limitations in functioning that cannot be met with the approved personal care aide (PCA) 40 hours per week. However, the documentation does not support that the patient has continuous needs that would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. The information supports personal are aide (PCA) 168 hours, live in, as medically necessary for this patient.
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Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Surgical Services.
The insurer denied Intracept procedure.
The patient is a female with complaints of low back pain. The patient continues to have low back pain. The patient completed physical therapy, but the pain continued. The patient is still doing home stretching. The patient also started chiropractic care. The patient was using non-steroidal anti-inflammatory drugs (NSAIDs). The pain is rated 6-7 out of 10, intermittent, and improved by lying down and heat. The physical exam demonstrated lumbar spine restricted lumbar range of motion, pain with lumbar flexion, straight leg raise negative bilaterally. The patient's diagnoses include vertebral genic low back pain. She has had prior lumbar injections. Magnetic resonance imaging (MRI) of the lumbar spine reported disc bulging with left central disc herniation at lumbar (L)3-4, multilevel disc degeneration.
The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve
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Upheld
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Experimental/Investigational
|
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Surgical Services.
The insurer denied Intracept procedure.
The denial is upheld.
The patient is a female with complaints of low back pain. The patient continues to have low back pain. The patient completed physical therapy, but the pain continued. The patient is still doing home stretching. The patient also started chiropractic care. The patient was using non-steroidal anti-inflammatory drugs (NSAIDs). The pain is rated 6-7 out of 10, intermittent, and improved by lying down and heat. The physical exam demonstrated lumbar spine restricted lumbar range of motion, pain with lumbar flexion, straight leg raise negative bilaterally. The patient's diagnoses include vertebral genic low back pain. She has had prior lumbar injections. Magnetic resonance imaging (MRI) of the lumbar spine reported disc bulging with left central disc herniation at lumbar (L)3-4, multilevel disc degeneration. The subject under review is whether the Intracept procedure is likely to be more beneficial for this patient than any standard treatment.
The proposed Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
| 1 |
Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
This patient is a male who presented to the emergency department with the complaint of right sided abdominal pain, loss of appetite, and diarrhea. The patient's vital signs at the time of presentation were normal. His examination revealed a tender right lower quadrant. The white blood cell (WBC) count was normal at 5.0 thousand. Hemoglobin was normal at 14.7. Bilirubin was elevated at 2.7. The patient's ultrasound showed a normal gallbladder and normal caliber common duct. Abdominal computed tomography (CT) showed a nonspecific mural hyperenhancement of the appendix without surrounding inflammation or definite stigmata of appendicitis. Surgical consultation was obtained. The patient was admitted to the hospital.
The patient was initially treated with nothing by mouth (NPO) status, intravenous (IV) fluid, antibiotics, and follow up lab data. The next day, the records indicate that the patient had normal vital signs and was considered to be stable for discharge home.
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Upheld
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Medical necessity
|
Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The denial is upheld.
This patient is a male who presented to the emergency department with the complaint of right sided abdominal pain, loss of appetite, and diarrhea. The patient's vital signs at the time of presentation were normal. His examination revealed a tender right lower quadrant. The white blood cell (WBC) count was normal at 5.0 thousand. Hemoglobin was normal at 14.7. Bilirubin was elevated at 2.7. The patient's ultrasound showed a normal gallbladder and normal caliber common duct. Abdominal computed tomography (CT) showed a nonspecific mural hyperenhancement of the appendix without surrounding inflammation or definite stigmata of appendicitis. Surgical consultation was obtained. The patient was admitted to the hospital.
The patient was initially treated with nothing by mouth (NPO) status, intravenous (IV) fluid, antibiotics, and follow up lab data. The next day, the records indicate that the patient had normal vital signs and was considered to be stable for discharge home.
The health plan rationale for denial of inpatient care was based on Milliman Care Guidelines Criteria 25th ed-General Admission Criteria.
No, the proposed inpatient hospital admission was not medically necessary.
In this case, inpatient care was not medically necessary. The care and treatment provided during this time could have been rendered with an observation level of care and did not require an inpatient designation. This lower level of care would have provided for surgical assessment, intravenous fluid, follow up, labs, and overnight monitoring.
Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The health plan acted reasonably and with sound medical judgment. Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored with an observational status.
This patient presented with abdominal pain. His evaluation with examination, lab data, ultrasound, and computed tomography scan identified abdominal tenderness but no obvious indication for acute surgical intervention. The patient was monitored overnight, and remained clinically stable during the period of monitoring.
This patient's clinical needs could have been satisfied with an observational level of care. This level of care would have provided for clinical assessment and monitoring including overnight observation as was performed.
| 1 |
Diagnosis: Huntington's disease and insomnia.
Treatment: CDPAP (Consumer Directed Personal Assistance Program) 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.
The insurer denied coverage for CDPAP 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.
.
This female has Huntington's disease, late stage with severe functional impairment. She is dependent on caregivers for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone and receives personal care services as Consumer Directed Personal Assistance Program (CDPAP) 84 hours per week.
The patient is incontinent of bladder and bowel, noted in UAS (Uniform Assessment System) as no control present. The patient is bedbound. It is noted there is a Hoyer lift for transfers, but it appears patient is no longer transferred to a toilet or commode; and so, all elimination is managed as incontinence care. The patient receives tube feeding 20 hours per day and hourly water flush in prescribed amounts as
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Overturned
|
Medical necessity
|
Diagnosis: Huntington's disease and insomnia.
Treatment: CDPAP (Consumer Directed Personal Assistance Program) 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.
The insurer denied coverage for CDPAP 12 hours per day- 7 days per week: 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week.
The denial is overturned.
This female has Huntington's disease, late stage with severe functional impairment. She is dependent on caregivers for all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient lives alone and receives personal care services as Consumer Directed Personal Assistance Program (CDPAP) 84 hours per week.
The patient is incontinent of bladder and bowel, noted in UAS (Uniform Assessment System) as no control present. The patient is bedbound. It is noted there is a Hoyer lift for transfers, but it appears patient is no longer transferred to a toilet or commode; and so, all elimination is managed as incontinence care. The patient receives tube feeding 20 hours per day and hourly water flush in prescribed amounts as recommended by a dietician (from the hospital and/or rehab facility), and so it is likely that bladder and bowel elimination occurs at multiple and various times during the day and night. Diapers are not the full solution to incontinence for a patient incapable of any type of self-help. Leaving the patient in soiled diapers for up to 12 hours is not consistent with medical and nursing standards for incontinence and skin care. Prolonged skin exposure to wet soiled diapers increases risk of incontinence associated skin damage (e.g., dermatitis, fungal infection) and increases risk of pressure ulcers. Incontinence can increase risk of urinary tract infection, especially with fecal incontinence. The patient needs a caregiver present throughout the day and night to ensure prompt attention to incontinence for the patient's health and comfort.
The patient is at high risk for pressure ulcers. She is totally dependent for bed mobility, and so she is unable to effectively reposition herself on a regular basis when she is in bed, which is currently where she spends most or all of her time. The patient's risk for pressure ulcer is also increased due to incontinence (another reason for ensuring prompt incontinence care). The patient was significantly underweight at the time of the UAS. Impaired nutrition is a risk factor for pressure ulcers. With tube feedings, her nutritional status may have improved, but nutritional risk may still be a concern.
The available information provides substantial support for medical necessity for 24-hour continuous services (i.e., split shift). Live-in services would not be adequate, as the patient's care needs are not compatible with the schedule of a live-in aide, which includes 5 uninterrupted hours of sleep per day (within 8 total hours of sleep per day), as per NYS (New York State) regulations for live-in aides. As described in this report, the patient's frequent care needs could not be properly met by an aide who is unavailable for 5 continuous hours per day; therefore, 24-hour continuous personal care services (in this case CDPAP) are indicated.
Consumer Directed Personal Assistance Program services, 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (split shift) - total of 168 hours per week is medically necessary.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP) 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (split shift) for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
| 1 |
Diagnosis: Arthrogryposis-renal dysfunction-cholestasis syndrome.
treatment: Inpatient stay.
The insurer denied the inpatient stay.
The patient is a male who has multiple medical problems as a result of arthrogryposis-renal dysfunction-cholestasis syndrome. He had a number of prior hospitalizations for gastrointestinal and renal complications, including electrolyte derangements such as hypernatremia due to polyuria and hypocalcemia. He is on multiple medications. His nephrologist determined that he required a central venous catheter (port placement) due to poor intravenous (IV) access, need for frequent blood draws and prior hospitalizations for dehydration. The port placement was scheduled and he was pre-admitted to the nephrology service for IV hydration and calcium correction while nothing by mouth (NPO) awaiting surgery.
to renal disease, for which he was on Epogen; modest elevations of blood urea nitrogen (BUN) and creatini
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Upheld
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Medical necessity
|
Diagnosis: Arthrogryposis-renal dysfunction-cholestasis syndrome.
treatment: Inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.
The patient is a male who has multiple medical problems as a result of arthrogryposis-renal dysfunction-cholestasis syndrome. He had a number of prior hospitalizations for gastrointestinal and renal complications, including electrolyte derangements such as hypernatremia due to polyuria and hypocalcemia. He is on multiple medications. His nephrologist determined that he required a central venous catheter (port placement) due to poor intravenous (IV) access, need for frequent blood draws and prior hospitalizations for dehydration. The port placement was scheduled and he was pre-admitted to the nephrology service for IV hydration and calcium correction while nothing by mouth (NPO) awaiting surgery.
The inpatient hospital admission was not medically necessary.
The patient was medically complex, but clinically stable when evaluated by nephrology prior to admission and when admitted pre-operatively. Labs showed some abnormalities. The nephrology note suggests that most of the abnormalities were stable, chronic issues (modest anemia, presumably due to renal disease, for which he was on Epogen; modest elevations of blood urea nitrogen (BUN) and creatinine consistent with chronic renal disease; mildly low albumin consistent with chronic gastrointestinal (GI) disease and failure to thrive; mild transaminitits consistent with chronic GI disease; and modestly low ionized calcium at 0.94 (consistent with chronic diseases). The only issues identified to manage pre-operatively were the need for intravenous fluids while NPO awaiting surgery and calcium correction. These two interventions can be performed at a lower level of care. There is no evidence that there were clinical issues that arose that would meet acute inpatient criteria.
| 1 |
Diagnosis: Nausea; vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The patient is a female. The patient presented with the complaint of nausea and vomiting. Findings were consistent with hypokalemia hypochloremia hyperbilirubinemia and elevated liver function tests.
The patient was admitted for management of hyperemesis gravidarum. She underwent a D&C (dilatation and curettage) for an elective termination of pregnancy. She left against medical advice.
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Overturned
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Medical necessity
|
Diagnosis: Nausea; vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The denial is overturned.
The patient is a female. The patient presented with the complaint of nausea and vomiting. Findings were consistent with hypokalemia hypochloremia hyperbilirubinemia and elevated liver function tests.
The patient was admitted for management of hyperemesis gravidarum. She underwent a D&C (dilatation and curettage) for an elective termination of pregnancy. She left against medical advice.
Yes, the Inpatient admission was medically necessary.
As per ACOG (American College of Obstetricians and Gynecologists), there are no controlled trials comparing hospitalization with outpatient management of hyperemesis gravidarum. When a woman cannot tolerate liquids without vomiting and has not responded to outpatient management, hospitalization for evaluation and treatment is recommended. After the patient has been hospitalized on one occasion and a workup for other causes of severe vomiting has been undertaken, intravenous hydration, nutritional support, and modification of antiemetic therapy often can be accomplished at home. Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in affect or who continue to lose weight.
According to UpToDate: Women who are unable to maintain adequate hydration, normal electrolyte levels, and acid-base balance should be admitted to the hospital for intravenous fluids and medications. Women who have severe vomiting, weight loss, ketonuria, dry mucous membranes, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital.
This patient was dehydrated with elevated liver function test, hypokalemia, hypochloremia, and hyperbilirubinemia. Admission to the hospital was medically necessary to manage her hyperemesis.
In addition, once in the hospital, the patient decided to proceed with an elective termination of pregnancy, which was performed during this admission. While such a procedure does not require hospital admission, the patient was already admitted to manage her hyperemesis and as such continued admission was medically necessary.
In summary, the inpatient hospital admission was medically necessary and indicated for managing this patient's medical condition.
No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has severe hyperemesis gravidarum necessitating hospital admission for electrolyte management. In addition the patient needed a termination of pregnancy. While this procedure is usually an outpatient procedure, the fact that the patient had hyperemesis gravidarum made the hospital admission medically necessary to manage her hyperemesis and to proceed with the D&C (dilatation and curettage).
| 1 |
Diagnosis: Finger amputation
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The patient is a male. He was noted to have sustained an injury that was related to a crush injury in a door with the need for a finger amputation. His noted comorbidities included schizophrenia and bipolar disorder.
Surgery was undertaken, removing part of the finger without complications. The hospital appeal letter described an individual with schizophrenic bipolar disease who presented to the emergency department with severe progressive worsening right middle finger digit pain new onset of discoloration secondary to traumatic crush injury secondary to catching his finger in a door. He had been hospitalized previously for the injury. He had an acute comminuted displaced fracture for which
to limited operating resources. Orthopedic Surgery was consulted at the time. Acute inpatient care was
because of severe progressive worsening of the right middle finger pain and discoloration. IV (intravenous) antibiotics were provided with the need for definitive surgical intervention. Surgery was undertaken for right distal third digit amputation.
Once clinically stabilized, it was felt that the patient could be discharged in accordance with the Millman care guidelines. It was felt
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Overturned
|
Medical necessity
|
Diagnosis: Finger amputation
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.
The patient is a male. He was noted to have sustained an injury that was related to a crush injury in a door with the need for a finger amputation. His noted comorbidities included schizophrenia and bipolar disorder.
Surgery was undertaken, removing part of the finger without complications. The hospital appeal letter described an individual with schizophrenic bipolar disease who presented to the emergency department with severe progressive worsening right middle finger digit pain new onset of discoloration secondary to traumatic crush injury secondary to catching his finger in a door. He had been hospitalized previously for the injury. He had an acute comminuted displaced fracture for which over reduction internal fixation cannot be undertaken due to limited operating resources. Orthopedic Surgery was consulted at the time. Acute inpatient care was recommended because of severe progressive worsening of the right middle finger pain and discoloration. IV (intravenous) antibiotics were provided with the need for definitive surgical intervention. Surgery was undertaken for right distal third digit amputation.
Once clinically stabilized, it was felt that the patient could be discharged in accordance with the Millman care guidelines. It was felt that due to the severity of presenting symptoms and high-risk for complications, close inpatient monitoring was recommended for the digital amputation. It was felt that this cannot be undertaken on an outpatient basis.
The emergency department record noted area of darkening and skin necrosis over the last of the right third digit sutures were in the digit itself distal right third digit. Surgery had been undertaken for the crush injury. He was admitted for surgery. The patient was noted to have history of bipolar disorder with necrosis of the right distal third digit with a comminuted displaced fracture. Surgery, ORIF (open reduction internal fixation) had been at the time secondary to limited Covid 19 (Coronavirus 2019) resources. Washout with laceration repair was done in the clinic. Healing was progressing until three days prior, with discoloration. The pain became problematic.
The patient was made nothing by mouth and given IV fluids for which surgery was recommended, with amputation. Noted under surgical pathology was the findings of necrotic right distal phalanx. The operative procedure was noted to include amputation of necrotic tissue proximal to the DIP (distal interphalangeal) joint, skin debrided and closed.
Yes, the inpatient hospital admission was medically necessary.
The inpatient hospital admission was medical medically necessary given the issues associated with necrotic tissue as related to the crush injury of the digit. Noted is that this individual had undergone a closure of the wound after crush injury, but could not undergo surgery because of problems associated with limited resources secondary to the Covid 19 pandemic.
In the consideration for amputation, the ODG (Official Disability Guidelines) guidelines were considered, stating the following in regards to amputation: "For chronic ischemia, amputation becomes an option when other re-vascularization efforts fail. Many traumatic fingertip amputations are best treated with initial irrigation and debridement followed by secondary intention wound closure. Revision finger amputation is acceptable for more complex injuries, allowing earlier return to work than replantation, which should be more strongly considered for the thumb and loss of multiple fingers."
The records clearly indicate that there was a degree of necrosis present, for which the surgical intervention was undertaken. As noted under Green's Operative Hand Surgery, under infections in the digits, it states the following: "When humoral and cellular immunity are impaired, it is critical that three important components of treatment be implemented: antibiotics, surgical debridement of the infected tissue, and increased immunity through improved nutrition. Poor nutrition, whether from alcoholism, cancer, major trauma, or inadequate diet, predisposes the patient to infections and poor wound healing that would otherwise be easily combated by healthy individuals." Notable, therefore, was that the importance of undergoing the amputation. The comorbidities involving schizophrenia and bipolar leads to the necessity for monitoring the condition to ensure that the individual is stable prior to discharge as was notable within the documents reviewed. Therefore, the treatment provided was medically necessary along with the in hospital stay in order to ensure stabilization of the condition. Particularly given the comorbidities present, the compliance can be compensated, for which the overnight stay rather than outpatient was considered reasonable. Therefore, the inpatient hospital admission was medically reasonable for the treatment of this individual's condition.
No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
In the consideration of the Millman Care Guidelines, the treatment for inpatient hospital admission can be indicated for an individual with "Newly diagnosed or suspected bone, joint, or orthopedic device infection (eg, osteomyelitis, septic arthritis) that requires 1 or more of the following (1)(2)(3):
1) IV [intravenous] antibiotics that cannot be initiated in other than inpatient setting (eg, patient too unstable or home infusion not available) 2) Device removal or replacement 3) Joint drainage (drain placement or repetitive aspirations) 4) Bone or soft tissue debridement."
Noted is that given that treatment had been delayed secondary to Covid 19 limitations in regards to resources, the issues associated with necrosis and infection were present, and septic arthritis, which required the degree of inpatient overnight stay. Also given the comorbidities that were notable as stated because of compliance issues, it was reasonable to provide the overnight stay for stabilization to ensure that no complications arose secondary to the surgical procedure for which the services provided were medically reasonable for the treatment of this individual's condition.
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Diagnosis: obstructive sleep apnea
Treatment: Oral Device/Appliance Custom Fabricated
The insurer denied coverage for Oral Device/Appliance Custom Fabricated
The
of sleep study results, and insurer correspondence, it appears that this patient with BMI (body mass index) 40.1 fatigue, snoring, and allergies, presented for recommendation on how to manage obstructive sleep apnea. The doctor recommended the oral appliance therapy as it was documented that the patient was/would be intolerant of the CPAP (continuous positive airway pressure) machine (as per the Affidavit). The insurer had denied the oral appliance therapy stating that the services is denied as the documentation provided and the
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Overturned
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Medical necessity
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Diagnosis: obstructive sleep apnea
Treatment: Oral Device/Appliance Custom Fabricated
The insurer denied coverage for Oral Device/Appliance Custom Fabricated
The denial is overturned
Upon review of submitted documentation which includes narrative reports and clinical progress notes, copies of sleep study results, and insurer correspondence, it appears that this patient with BMI (body mass index) 40.1 fatigue, snoring, and allergies, presented for recommendation on how to manage obstructive sleep apnea. The doctor recommended the oral appliance therapy as it was documented that the patient was/would be intolerant of the CPAP (continuous positive airway pressure) machine (as per the Affidavit). The insurer had denied the oral appliance therapy stating that the services is denied as the documentation provided and the clinical findings offered does not support/meet their medical necessity criteria and the is no documentation that CPAP was attempted.
Based on the documentation provided, it is clear, based on the results of the sleep study, that the patient exhibits obstructive sleep apnea. Although CPAP therapy is considered the gold standard treatment for this condition, other therapies such as oral appliance therapy are accepted treatment modalities and FDA (Food and Drug Administration) approved in those cases in which CPAP is unable to be tolerated or no longer effective. In this case, the affidavit states CPAP could not be tolerated and therefore the oral appliance therapy was recommended, Peer reviewed literature (see below references) indicates that an oral appliance is an effective treatment for obstructive sleep apnea. Further, this patient does fulfill accepted clinical criteria for oral appliance therapy. As such the oral appliance therapy is considered medically necessary.
Overturned denial and approve coverage for an oral appliance, as medically necessary as it fulfills the standard criteria and is an accepted treatment modality in this clinical circumstance.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the Oral Device/Appliance Custom Fabricated is overturned. Medical Necessity is substantiated.
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Diagnosis: Ulcerative Colitis
Treatment: Stelara (every 4 weeks), Pre-service
The insurer denied the Stelara (every 4 weeks), pre-service.
The patient is a male who has the diagnosis of inflammatory bowel disease. Specifically, the patient had been diagnosed with ulcerative colitis (UC). The patient received Stelara as treatment for this condition. As the patient evidenced increasing symptoms attributable to their condition, the provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks.
The patient has a medical diagnosis of UC. The patient has the diagnosis of inflammatory bowel disease (IBD). Specifically, the patient has the diagnosis of UC. The patient has received Stelara as treatment for this condition. The patient evidenced increasing symptoms attributable to their condition between dosing. The treating provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. The provider has requested Stelara at a dosing
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Overturned
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Experimental/Investigational
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Diagnosis: Ulcerative Colitis
Treatment: Stelara (every 4 weeks), Pre-service
The insurer denied the Stelara (every 4 weeks), pre-service.
The denial is upheld.
The patient is a male who has the diagnosis of inflammatory bowel disease. Specifically, the patient had been diagnosed with ulcerative colitis (UC). The patient received Stelara as treatment for this condition. As the patient evidenced increasing symptoms attributable to their condition, the provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. This is the subject of this review.
No, the health plan should not cover the Stelara every 4 weeks.
The use of Stelara (ustekinumab) subcutaneously (SQ) 90 mg (milligrams) every 4 weeks is not medically appropriate for this patient with UC.
The patient has a medical diagnosis of UC. The patient has the diagnosis of inflammatory bowel disease (IBD). Specifically, the patient has the diagnosis of UC. The patient has received Stelara as treatment for this condition. The patient evidenced increasing symptoms attributable to their condition between dosing. The treating provider has requested the provision of Stelara at a decreased dosing interval of every 4 weeks. The provider has requested Stelara at a dosing not approved by the FDA (United States Food and Drug Administration). A review of the literature indicates that there have been no significant studies to date demonstrating the safety and efficacy of Stelara dose escalation to every 4 weeks in UC. Therefore, the request for Stelara SQ 90 mg every 4 weeks is denied and not medically appropriate for this patient.
"The efficacy of antibody-based therapeutics depends on their pharmacokinetics. The pharmacokinetic and exposure response profiles of ustekinumab, a monoclonal antibody against interleukin 12/interleukin 23, are known in patients with Crohn's disease, yet there are few data from patients with ulcerative colitis." (Adedokun, et al)
"The efficacy of ustekinumab, an antagonist of the p40 subunit of interleukin-12 and interleukin-23, as induction and maintenance therapy in patients with ulcerative colitis is unknown." (Sands, et al)
"A subset of patients with Crohn's disease (CD) do not respond to ustekinumab at the standard dose of 90 mg every 8 weeks. Little is known about the efficacy of shortening the interval between doses." (Ollech, et al)
No, Stelara every 4 weeks is not more beneficial.
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Diagnosis: Cardiac/Circulatory Problems- Hyperlipidemia
Treatment: Prescription/Pharmacy Drugs-Repatha
The health plan denied the requested treatment of Repatha as not medically necessary.
The patient has a history of hypertension, hyperlipidemia, obesity, hepatic steatosis, and abnormal liver function tests. His coronary artery calcium score was 16.62, which placed him in the 46th percentile for his age, race, and sex. Recently, his low-density lipoprotein (LDL) cholesterol level was 141 milligrams per deciliter (mg/dl). At that time, he was on ezetimibe. Prior therapy with statins had been discontinued due to elevated liver function tests (LFTs).
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Upheld
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Medical necessity
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Diagnosis: Cardiac/Circulatory Problems- Hyperlipidemia
Treatment: Prescription/Pharmacy Drugs-Repatha
The health plan denied the requested treatment of Repatha as not medically necessary. The reviewer has upheld the determination in whole.
The patient has a history of hypertension, hyperlipidemia, obesity, hepatic steatosis, and abnormal liver function tests. His coronary artery calcium score was 16.62, which placed him in the 46th percentile for his age, race, and sex. Recently, his low-density lipoprotein (LDL) cholesterol level was 141 milligrams per deciliter (mg/dl). At that time, he was on ezetimibe. Prior therapy with statins had been discontinued due to elevated liver function tests (LFTs).
Based on the documentation provided Repatha is not medically necessary.
Repatha (evolocumab) is a member of a class of lipid-lowering agents called Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors. At the present time it is Food and Drug Administration (FDA) approved and recommended for use only in patients with established atherosclerotic cardiovascular disease (ASCVD) or those with primary hyperlipidemia, including familial hypercholesterolemia. These indications were selected since these subgroups have the highest risk of future cardiovascular events and were previously studied in phase II and III lipid-lowering trials. While there have been several trials examining the use of PCSK9 inhibitors in other patient subgroups, the data regarding their use in these lower risk groups are limited. Current guidelines, including the 2017 Focused Update of the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk and the 2017 National Lipid Association Update on the Use of PCSK9 inhibitors, do not support the use of PCSK9 inhibitors, such as Repatha, for patients without a diagnosis of ASCVD or primary hyperlipidemia unless their baseline LDL cholesterol level is 190 mg/dl or greater.
This man's coronary artery calcium score previously was 16.62. While this indicated the presence of some atherosclerotic plaque in his coronary arteries, scores in this range suggest minimal disease and a low risk of significant stenosis. No more recent score was provided. Per a panel of experts convened by the American Society for Preventive Cardiology "Clinical ASCVD includes acute coronary syndromes, history of myocardial infarction (MI), stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral arterial disease presumed to be of atherosclerotic origin, as well as other forms of atherosclerotic vascular disease including significant atherosclerosis of the coronary, carotid, iliofemoral circulations, and the aorta." This patient does not meet this definition. Thus, given the information provided, he cannot be considered to have established ASCVD. In addition, current guidelines do not recommend the use of Repatha unless a patient's LDL cholesterol level remains above goal despite maximally tolerated statin therapy or the patient is statin intolerant. Based on the information provided it is unclear if this patient has true statin intolerance. LFT abnormalities are common in patients on statin therapy and are not, in themselves, an indication for drug discontinuation. Discontinuation is recommended when transaminase levels greater than three times the upper limit of normal occur on two or more occasions or if the patient develops jaundice, and where secondary causes of elevations in hepatic transaminase levels have been ruled out. The records provided do not document that this is the case. Finally, hepatic steatosis (fatty liver) is not necessarily a contraindication to statin therapy; in fact, statins may be beneficial in patients with this condition.
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Diagnosis: Congestive Heart Failure (CHF).
Treatment: inpatient admission.
The insurer denied coverage for inpatient admission.
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Upheld
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Medical necessity
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Diagnosis: Congestive Heart Failure (CHF).
Treatment: inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.
The patient has a history of hypertension, and CHF (congestive heart failure). He presented to the emergency department (ED) with complaints of worsening shortness of breath (SOB) and swelling of his feet. He had been non-compliant with his medications. At presentation to the hospital, vital signs were temperature (T) 98, heart rate (HR) 99, respiratory rate (RR) 20, blood pressure (BP) 162/101 and oxygen (O2) saturations of 92% (percent) on room air (RA). The patient was noted to be using some accessory muscles for respiration. He was alert and oriented times 3. The lung exam revealed some decreased air entry and wheezing. There was edema of the lower extremities was noted.
Labs were significant for sodium (Na+) 133, blood urea nitrogen (BUN)/ creatinine (Cr) 16/1.49, Troponin 0.05, B-type natriuretic peptide (BNP) 13000. EKG (electrocardiogram) showed sinus tachycardia, left ventricular hypertrophy (LVH), premature ventricular contractions. Chest X ray revealed right pleural effusion with atelectasis/infiltrate in right lung base.
The patient was placed on BiPAP (bilevel positive airway pressure) initially but did not tolerate it, so he took it off. He was treated with intravenous (IV) Lasix. Started on empiric antibiotics Vancomycin/Rocephin. The patient was treated with IV hydralazine initially for elevated blood pressure. He was admitted to the hospital for treatment of CHF.
As per the Nursing note in ED, the patient was alert and oriented times three and in no acute distress. He denied SOB or chest pain with ambulating and had refused further BiPAP. The patient also refused the previous night. Oxygen saturation was 98% on RA. Repeat chest X-ray revealed some improvement of prior findings. The patient was feeling better and decided to go home. He signed out AMA (against medical advice).
Lungs were described as clear to auscultation. The patient was not hypoxic and did not require oxygen. The patient was sent home on oral medication.
This patient did not need acute hospitalization. His symptoms of elevated BP were related to noncompliance with medications. He could have been placed in observation status while diagnostic testing and treatment were initiated. The patient could have been treated with IV diuretics initially; myocardial infarction was ruled out. The patient was feeling better, was not hypoxic and lungs were clear. He was feeling well and at baseline and wanted to go home. Decided to sign out AMA. This patient could have been placed in Observation and subsequently discharged home after a period under observation on oral meds with close follow up in outpatient setting.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
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Diagnosis: Dementia, Osteoarthritis.
Treatment: Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The insurer denied Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
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Overturned
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Medical necessity
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Diagnosis: Dementia, Osteoarthritis.
Treatment: Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The insurer denied Personal care services - 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
The determination is overturned.
The patient has a medical history of dementia, diabetes mellitus type 2, glaucoma of the right eye, vision loss of the left eye, osteoarthritis of the cervical (C)-spine and lumbar (L)-spine, end stage renal disease (ESRD) on hemodialysis, coronary artery disease (CAD), status post percutaneous coronary angioplasty, osteoarthritis of bilateral knees, severe protein-calorie malnutrition, diabetic neuropathy, cancer of the sigmoid colon, urinary incontinence, and bowel incontinence and had been assigned personal care assistant (PCA) services 10 hours/day, 4 days/week and 7 hours/day, 3 days/week.
The patient sustained falls and there was a request to increase PCA services. The patient underwent an assessment assessing the patient at total assistance with the tasks of meal preparation, ordinary housework, transportation, bathing, dressing lower body, locomotion, toilet use, and bed mobility while maximum assistance with tasks of managing finances, phone use, personal hygiene, and dressing upper body. The patient was assessed at extensive assistance with task of managing medication, equipment management, and eating, and the assessor noted activity did not occur for tasks of walking and transfer toilet. Notes from the assessment stated the patient had a decline in activities of daily living (ADL) status and a deterioration in overall self-sufficiency over the last 90 days. The notes also stated the patient was unable to wheel himself in a wheelchair, required a Hoyer lift for transfers, and needed to be turned and repositioned every 2 hours because he was unable to do so himself.
The insurer provided an initial adverse determination denial notice denying the request to increase PCA services stating the daughter did not identify any tasks that were not being met with his current schedule, there was no medical need for him to get up at night, overnight service was for safety supervision which was not a covered benefit, they recommended an over bed table to help reach objects he may need, they also recommended a thermal plate to keep his food warm, and they recommended following up with the nursing home transition and diversion Medicaid waiver program. In addition, the denial letter stated the patient could use a bed cane to help with moving in and out of bed, they recommended an alternating mattress for his bed to reduce pressure on bony prominences, the plan also recommend physical therapy, they recommended a condom catheter at night to meet his nighttime toileting needs, the plan recommended limiting fluid intake after 6 PM to lessen nighttime urination, and they recommended splitting his hours into 2 shifts to better meet his care needs.
The patient's primary care physician (or provider) (PCP) provided a letter documenting the patient's medical diagnoses and the need for assistance to complete ADLs both day and night. The doctor noted the patient had an adult daughter who was very involved with his care but did not live with him. The PCP letter also stated that due to the patient's advanced arthritis he was bedbound and could no longer transfer without assistance and despite several episodes of physical therapy (PT) / occupational therapy (OT) he has not been successful at restoring function. The provider also noted the patient had has had frequent loose stools since his colon cancer surgery and has bowel incontinence both day and night. She noted the patient must be transferred with a Hoyer lift and although he is able to use a diaper is unable to change the diaper alone. In addition, the patient's PCP stated the patient is unaware of his incontinence and must be checked regularly and soiled diapers must be changed promptly, even in the overnight. The provider also noted the patient is unable to reheat his meals and must be able to eat a small snack in response to potential low blood glucose in the middle of the night. Lastly, the provider stated it was in her opinion that the patient required 24-hour home care and split shifts in order to maintain his health and prevent loss of further function and hospitalization and skilled nursing facility (SNF) placement was not appropriate as this was clearly against his wishes. The insurer provided a final adverse determination denial notice partially approving PCA services to 64 hours/week. The patient was seen by a visiting doctor at home for a lump in the abdomen which was felt to be a hernia although patient did not have any complaints of pain and it was determined this would be monitored.
At issue is the medical necessity of personal care services- 24 hours a day, 7 days a week (split shift) for a total of 168 hours.
Yes, the services are medically necessary.
There is documentation of both cognitive and functional decline by the patient with a request to increase PCA services. Following the patient's colon cancer surgery, he has had bowel incontinence and is unable to transfer or change diaper. The patient requires total assistance with the tasks of walking, locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The insurer's own assessment documented the patient needed to be turned and repositioned every 2 hours in order to prevent skin breakdown. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADLs). The patient had participated in physical therapy and occupational therapy on multiple occasions without restoration of function. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient sometimes requires a snack in the night due to hypoglycemia from his diabetes. The patient's overnight care needs would not allow an aide to obtain at least 5 hours of uninterrupted sleep. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
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Diagnosis: Digestive System/Gastrointestinal/Gallbladder Problem/Infected Gallbladder
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary.
The patient is a woman who presented to the emergency department (ED) with recurrent right sided abdominal pain. At the time of presentation, the patient was without fever and the heart rate was 74/minute. She had a tender abdomen per the examination. The white blood cell (WBC) count was normal at 6.3 K. The complete metabolic panel was normal. An ultrasound showed findings of gallstones. She was initially treated with intravenous (IV) fluid and IV antibiotics. She was admitted to the hospital and started on IV antibiotics. The patient was reported to have improved pain and was started on a liquid diet. A routine preoperative COVID test returned positive and plans for a cholecystectomy during this admission were postponed. The patient remained clinically stable and was discharged from the inpatient setting with instructions for outpatient follow up.
This patient is a woman who presented to the hospital with abdominal pain. The records and her diagnostic work
a COVID test revealed a positive result, plans for surgery were
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Upheld
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Medical necessity
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Diagnosis: Digestive System/Gastrointestinal/Gallbladder Problem/Infected Gallbladder
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary.
The health plan's determination is upheld.
The patient is a woman who presented to the emergency department (ED) with recurrent right sided abdominal pain. At the time of presentation, the patient was without fever and the heart rate was 74/minute. She had a tender abdomen per the examination. The white blood cell (WBC) count was normal at 6.3 K. The complete metabolic panel was normal. An ultrasound showed findings of gallstones. She was initially treated with intravenous (IV) fluid and IV antibiotics. She was admitted to the hospital and started on IV antibiotics. The patient was reported to have improved pain and was started on a liquid diet. A routine preoperative COVID test returned positive and plans for a cholecystectomy during this admission were postponed. The patient remained clinically stable and was discharged from the inpatient setting with instructions for outpatient follow up.
At issue is the medical necessity for the inpatient stay.
The health plan's determination is upheld, in whole.
No. An inpatient level of care was not medically necessary in this case. This patient is a woman who presented to the hospital with abdominal pain. The records and her diagnostic work up supported the diagnosis of cholelithiasis/biliary colic, and this diagnosis was established. When a COVID test revealed a positive result, plans for surgery were postponed per protocol. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care. Additionally, there is no documentation of failure to achieve discharge criteria, care for comorbidities, or any other condition requiring an inpatient admission. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with an alternative level of care. An alternative level of care would have provided for ED assessment, surgical consultation, monitoring, provision of IV antibiotics and fluid, and overnight care. The records in this case support the medical necessity of a cholecystectomy, though this procedure was not performed during this hospital presentation.
There is no clinical documentation to support the need for inpatient admission or why this patient could not have safely and appropriately been treated at an alternative level of care. The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. The serum chemistries were normal at the time of presentation. Based on the submitted clinical documentation, an inpatient level of care was not medically necessary. The patient was treated non-operatively during this admission with planned outpatient follow up due to a positive COVID test. There were no hospital complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital.
Inpatient level of care was not medically necessary. An alternative level of care would have permitted for the ED and surgical assessment, imaging, lab data, IV fluid, IV antibiotics, IV antiemetics, and overnight monitoring. The patient remained clinically stable as supported by the corresponding medical records. She was tolerating a liquid diet and oral analgesia.
Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case, none of these conditions existed to warrant an inpatient level of care.
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Diagnosis: Respiratory/Asthma.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care assistant hours.
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Overturned
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Medical necessity
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Diagnosis: Respiratory/Asthma.
Treatment: Home Health Care.
The health plan denied the requested increase in personal care assistant hours.
The health plan's determination is overturned.
The patient is a female with a past medical history of urinary incontinence, hypertension, asthma, memory loss, wheelchair bound status, deep vein thrombosis (DVT)/pulmonary embolism (PE) with chronic anticoagulation, gastroesophageal reflux disease (GERD), and breast cancer who had been assigned personal care assistant (PCA) services 24 hours per week. There was a request to increase PCA services and the patient underwent an assessment assessing the patient at total assistance with tasks of ordinary housework, stairs, and shopping while maximum assistance with tasks of meal preparation, managing finances, transportation, bathing, dressing lower extremity, walking, and locomotion. With tasks of managing medication, phone use, personal hygiene, dressing upper body, transfer toilet, and toilet use the patient was assessed at extensive assistance, while limited assistance with tasks of bed mobility and eating. The patient was seen by her medical provider for an asthma exacerbation. On the same date, the provider filed a report stating the patient needed a home health aide at all times for minimal ambulation, monitor vital signs, diaper changing, was bedbound and required 24 hours of home health aide services. The patient's medical provider filed another report noting patient had gait abnormality, moderate asthma, was wheelchair bound and needed 24-hour service. The patient's medical provider completed another report stating the medical diagnoses of the patient and the patient required 24-hour home health aide services and had been hospitalized 3 times in the past year. The patient's primary care physician (PCP) provided a letter stating the patient was bedbound with a history of repeated falls and needed 24-hour home health aide secondary to memory loss, persistent dizziness, and pulmonary embolism. The patient's daughter provided a letter appealing denial decision stating the daughter lives with the patient and the daughter could no longer take care of the patient due to the daughter's own full-time work. The daughter noted the patient could not be left alone, the patient had severe respiratory problems, the patient had worsening memory, and had multiple falls.
At issue is the medical necessity for the requested increase in personal care assistant hours.
The health plan's determination of medical necessity is overturned, in whole.
Yes, PCA services 12 hours/day, 5 days/week, and 9 hours/day, 2 days/week to total 78 hours/week are medically necessary for this patient.
There is documentation by the patient's primary care provider of the medical necessity of increased PCA services. There is documentation by the patient's PCP and the patient's daughter of worsening cognitive and functional status. The daughter is no longer able to provide informal support at the amount of time the patient requires assistance. The patient requires assistance with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The patient has unscheduled and unpredictable care needs that span a continuum of time to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 5 days/week and 9 hours/day, 2 days/week to total 78 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
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Diagnosis: Syncope.
Treatment: Inpatient emergency admission.
The insurer denied coverage for inpatient emergency admission.
The patient presented to the emergency department after an episode of syncope. The patient was postoperative day three after conversion of a sleeve gastrectomy to a gastric bypass. Vital signs on presentation were a blood pressure of 112/63 millimeters of mercury (mmHg) and a pulse of 81 beats per minute (bpm). Hemoglobin was noted to be 6.9. The patient was transfused one unit in the emergency department. A computed tomography (CT) scan of the chest, abdomen, and pelvis was negative for any acute pathology. Repeat hemoglobin was noted to be 7.4 and 6.8 the following day. The patient was then transfused an additional two units of blood.
transfusion. Clinical documentation notes that the patient presented after a syncopal episode and was noted to be hypotensive by Emergency Medical Services (EMS)
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Overturned
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Medical necessity
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Diagnosis: Syncope.
Treatment: Inpatient emergency admission.
The insurer denied coverage for inpatient emergency admission.
The denial is overturned.
The patient presented to the emergency department after an episode of syncope. The patient was postoperative day three after conversion of a sleeve gastrectomy to a gastric bypass. Vital signs on presentation were a blood pressure of 112/63 millimeters of mercury (mmHg) and a pulse of 81 beats per minute (bpm). Hemoglobin was noted to be 6.9. The patient was transfused one unit in the emergency department. A computed tomography (CT) scan of the chest, abdomen, and pelvis was negative for any acute pathology. Repeat hemoglobin was noted to be 7.4 and 6.8 the following day. The patient was then transfused an additional two units of blood. Per Milliman Care Guidelines (MCG) guidelines, admission for anemia is indicated in patients with recurrent syncope or near syncope or clinically significant signs or symptoms that are severe or persist despite observation care (example (e.g.), transfusion, volume replacement). [1] The patient's hemoglobin did not increase appropriately after initial transfusion. Clinical documentation notes that the patient presented after a syncopal episode and was noted to be hypotensive by Emergency Medical Services (EMS). Based on provided clinical documentation, the inpatient admission was medically necessary.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for inpatient emergency admission is overturned. Medical Necessity is substantiated.
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Diagnosis: Gender dysphoria
Treatment: Tracheal shave surgery
The insurer denied coverage for tracheal shave surgery
The
involves a transgender who was being recommended for tracheal shave as an initial gender affirming surgery. The patient was seeing a private voice feminization coach and endorsed vocal fatigue when trying to modify the sound of her voice. The patient was being recommended for tracheal shave to reduce the thyroid cartilage prominence. A progress notes stated that the patient was just beginning her transition, which started with hormone replacement therapy. She was working with a private voice feminization coach to address her pitch, elevation, color, and resonance. On examination, there was tension with phonation in the thyrohyoid space or tongue base with prominent thyroid cartilage notch and a thin neck. A 70-degree rigid endoscopy with stroboscope was performed to assess the oropharynx and surrounding structures. The proposed surgery was denied with the final adverse determination letter stating that the plan does
functional defect. Prior appeal letters indicated that the patient was diagnosed with gender dysphoria and expressed persistent desire for tracheal shave surgery.
. The physician stated the patient was mentally stable and had fully explore the risks, benefits,
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Upheld
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Medical necessity
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Diagnosis: Gender dysphoria
Treatment: Tracheal shave surgery
The insurer denied coverage for tracheal shave surgery
The denial is upheld
This case involves a transgender who was being recommended for tracheal shave as an initial gender affirming surgery. The patient was seeing a private voice feminization coach and endorsed vocal fatigue when trying to modify the sound of her voice. The patient was being recommended for tracheal shave to reduce the thyroid cartilage prominence. A progress notes stated that the patient was just beginning her transition, which started with hormone replacement therapy. She was working with a private voice feminization coach to address her pitch, elevation, color, and resonance. On examination, there was tension with phonation in the thyrohyoid space or tongue base with prominent thyroid cartilage notch and a thin neck. A 70-degree rigid endoscopy with stroboscope was performed to assess the oropharynx and surrounding structures. The proposed surgery was denied with the final adverse determination letter stating that the plan does not cover cosmetic procedures and was related to reconstructive surgery from trauma, infection, or diseases of the involved part, or because of a congenital disease or anomaly, which has resulted in a functional defect. Prior appeal letters indicated that the patient was diagnosed with gender dysphoria and expressed persistent desire for tracheal shave surgery. The goals of surgery were to be able to live more fully in a gender role congruent with her affirmed gender. It was believed that surgery was the best way to achieve these goals and to further alleviate her gender dysphoria. The physician stated the patient was mentally stable and had fully explore the risks, benefits, and alternatives of the surgery.
The health plan has indicated that certain ancillary procedures, including but not limited to the following are considered cosmetic and not medically necessary, when performed as part of a surgical treatment for gender dysphoria. This includes trachea shave. Medical literature states that chondrolaryngoplasty, or "tracheal shaving," is a cosmetic procedure designed to reduce the prominence of the thyroid cartilage. Records indicate the patient was medically stable, understanding the risks and benefits of the surgery, although she reported significant anxiety, depression, and distress due to her experience of dysphoria. While the patient may be a suitable candidate for the procedure given her understanding of the risks and benefits of surgery, and with the indications that this would reportedly help with her gender dysphoria, this is considered a cosmetic procedure in general. For all other gender reassignment procedures, patients are required to have written psychological assessment from at least 2 qualified behavioral health providers experienced in treating gender dysphoria, have independently assessed the individual, and have included all of the following to include that the member is capable to make a fully informed decision and has consented for treatment, is at least 18 years of age, has any significant medical or mental health concerns reasonably well controlled, has completed least 12 months of successful continuous full-time real-life experience in the desired gender, and has completed 12 months of continuous cross-sex hormone therapy appropriate for the desired gender (unless medically contraindicated). The records provided for the review did not include that the patient was assessed by two qualified mental health specialists nor was their confirmation that the patient completed at least 12 months of successful continuous full-time real-life experience in the desired gender.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for tracheal shave surgery is upheld. Medical Necessity is not substantiated.
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Diagnosis: abdominal pain
Treatment: inpatient admission
The insurer denied coverage for inpatient admission
The
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Upheld
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Medical necessity
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Diagnosis: abdominal pain
Treatment: inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld
This is an adult with a history gastric bypass twenty years ago. The patient presented to the emergency department (ED) complaining of generalized abdominal pain for 4 days with nausea but no vomiting. The patient had gone first to the urgent care center for these symptoms and had blood work and was recalled because liver function tests (LFT's) were elevated. She was advised to go to the emergency department (ED). The patient denied any vomiting or fever or chills. The patient's vital signs were stable. An examination revealed scleral icterus and abdominal tenderness without guarding or rebound. The plan was sonogram and possible computed tomography (CT). The ultrasound showed acute cholecystitis with moderate gallbladder wall thickening. There was no dilation of the hepatic ducts. The pancreas body was unremarkable. The patient was tolerating an oral intake, was started on Flagyl and Rocephin and was admitted.
On surgical consultation, the white blood cell (WBC) count was 8.3. The impression was acute cholecystitis versus choledocholithiasis. Given the patient's history, the patient would require common bile duct (CBD) exploration versus intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) through the gastric pouch. A magnetic resonance cholangio- pancreatography (MRCP) was done and demonstrated no stone in the common bile duct (CBD) and no acute cholecystitis. The liver function tests (LFT's) were down trending and the patient was feeling well without vomiting and had no pain at rest.
Repeat labs showed a white blood cell (WBC) count of 6.0, aspartate aminotransferase (AST) level of 313, alanine aminotransferase (ALT) level of 542, total bilirubin 3.5, direct bilirubin 2.0 and alkaline phosphatase (alk phos) of 298.
Because the liver function tests (LFT's) were down trending, it was felt that the patient had passed a stone or sludge. The patient continued on nonoperative management and clinically improved. The patient's diet was advanced, and the patient was discharged home on oral antibiotics.
According to the guideline Milliman Care Guideline (MCG) Health Inpatient and Surgical Care- 27th edition Gall Bladder or Bile Duct Inflammation or Stone ORG: M-555 (ISC), the clinical indications for admission to inpatient care were not met.
Milliman Care Guidelines (MCG) Health in General Recovery Care 27th edition General Admission Criteria GRG: CG-GAC (ISC GRG) were also not met to indicate inpatient admission necessity.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
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Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
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Upheld
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Medical necessity
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Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.
The patient has a history of chronic obstructive pulmonary disease (COPD) on home oxygen (O2) 4 liters (L) by nasal cannula (NC), pulmonary embolism (PE) on NOAC (new oral anticoagulants), schizophrenia and bipolar disorder. The patient also has chronic lower extremity (LE) stasis ulcers. He was brought to the emergency department (ED) at the recommendation of his home health aide, who felt the patient was more short of breath (SOB) and also complained of some worsening of LE cellulitis/ulcers along with pain. As per reports, the patient's O2 saturations at home on 4 liters nasal cannula (NC) ranged from 76-89% (percent). Vital signs (V/S) at presentation to ED were temperature (T) 98, heart rate (HR) 97, respiratory rate (RR) 15, blood pressure (BP) 125/70 mm Hg (millimeters of mercury), O2 saturations 74%. The patient however did not report any respiratory distress. He said he was at his baseline. Shortly afterwards, V/S were T 98, HR 88, BP 115/72, and O2 saturation was 86%. The patient was in no acute distress (NAD). Labs revealed white blood cell count (WBC) 3.5K (thousand). Hemoglobin (Hb) was 15.7 and electrolytes were essentially normal. Brain natriuretic peptide (BNP) was 89, and venous blood gas (VBG) was 7.34/62/34.
Chest X-ray (CXR) revealed chronic interstitial changes. There was no acute pathology. CXR was essentially unchanged. Ultrasound of the lower extremities showed no venous insufficiency. The patient was treated with intravenous (IV) antibiotics, pain medications and bronchodilators in the ED. The patient was placed on bilevel positive airway pressure (BIPAP) for some time. As per note from ED, the patient was substantially improved. O2 saturation was 91% on 6L NC.
The patient was admitted to the hospital for COPD and LE cellulitis. At the time of the history and physical (H&P), the patient denied any SOB, chest tightness, fever or chills. Lungs had good air entry bilaterally. Occasional end expiratory wheeze was heard. Chronic stasis ulcer noted over LE. No erythema. Granulation tissue noted. The patient remained stable after admission. As per H&P, COPD was not in exacerbation. LE stasis ulcers. The patient was feeling better. Afebrile and hemodynamically (HD) stable, lungs good air entry.
The patient was saturating 90% on 5L NC. This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was at his baseline. O2 saturations were close to baseline a few hours after presentation. The patient denied any symptoms of COPD exacerbation. The patient's LE ulcers were chronic. No infection noted. The patient was afebrile with normal WBC. No pneumonia (PNA) on CXR. Vascular surgery follow-up arranged as outpatient.
This patient could have been discharged home after a period in observation status during which diagnostic testing and treatments could have been initiated. Observation could be for up to 48 hours. The patient had stabilized long before that and was discharged on the day after admission in about 24 hours. The patient was to continue his supplemental O2. O2 saturations were close to baseline. The patient was to continue maintenance COPD meds and follow up with vascular surgery in outpatient setting.
The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
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