Answer:
Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

Answer:
According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring.

Answer: This is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.

Answer: This patient presented with atypical chest pain and a past medical history of hypertension.

Context:
Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the documentation submitted, this is the case of a patient with a history of diabetes mellitus and hypertension. The patient presented to the Emergency Department (ED) due to chest pain, and headache. The patient was admitted to inpatient telemetry level for continued evaluation, monitoring, and treatment. The patient had a cardiology consult, X-ray, intravenous (IV) Toradol, cardiac monitoring, and continuous pulse oximetry.

The insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter, they write that a review of the records shows that the patient could have been placed in observation under monitoring. The patient could have had an evaluation by professional(s), had testing and been treated symptomatically while awaiting test results. The admission does not meet clinical criteria.

This is a patient with a past medical history of diabetes mellitus and hypertension that presented to the hospital with chest pain.  On arrival to the hospital, vital signs were stable: blood pressure (BP) 126/84, pulse 82.  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities.  Serum blood testing revealed no major abnormality.  Computed tomography (CT) chest revealed coronary artery calcium.  The patient was treated with Toradol and discharged with cardiology follow up.

This patient presented with atypical chest pain and a past medical history of hypertension. The patient's pretest probability of coronary artery disease was low (1).  Utilizing the HEART (identifies cardiac risk) score the patient was considered low risk (2).  Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed (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 all-cause 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. This patient could have been treated at a lower level of care.

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 inpatient hospital admission is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease

Treatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary.

Answer:
The patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.
At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

Context:
Diagnosis: Central Nervous System/Neuromuscular Disorder/Alzheimer's Disease

Treatment: Home Health Care/Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan denied the requested Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week as not medically necessary.

The health plan's determination is overturned.

The patient is a female with a history of osteoarthritis (OA), Alzheimer's and diabetes mellitus (DM). They were recently hospitalized for congestive heart failure (CHF) and aspiration pneumonia. As a result, the patient has severe limitation in activities of daily living such as weight bearing support for dressing, bathing and commode use. They have stiffness, weakness, limited range of motion, incontinence and cognitive impairment. They require maximum to total assistance, as well as oxygen treatment.
At issue is the medical necessity for the requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week.

The health plan's determination of medical necessity is overturned, in whole.

Yes. The requested health service/treatment of Personal Care Aide (PCA) Level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is medically necessary for this patient
Skilled nursing home health care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care. Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively. Care that can be given by non-professional staff is not considered skilled nursing care. The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.
In this case, the patient has severe or extensive functional limitations which would substantiate the need for the requested health care services.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Septic arthritis and osteomyelitis
Treatment: Subacute rehab stay
The insurer denied Subacute rehab stay.

Answer:
This a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.
Therapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.
The health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.

Answer: The patient is being treated for rehabilitation following a surgical procedure and infection of the leg.

Answer: The patient had a substantial decline in functional status as a result of his infection and surgery.

Context:
Orthopedic/Musculoskeletal
Inpatient Rehabilitation

Diagnosis: Septic arthritis and osteomyelitis
Treatment: Subacute rehab stay
The insurer denied Subacute rehab stay.
The determination is overturned.

This a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.
Therapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.
The health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.

The requested treatment is medically necessary for the patient.
The patient is being treated for rehabilitation following a surgical procedure and infection of the leg. Rehabilitation in an inpatient setting is typically continued until patients reach their maximum therapeutic potential as outcomes are maximized with intensive early interventions. The patient had a substantial decline in functional status as a result of his infection and surgery. Given his favorable prognosis for meaningful recovery of function, ongoing therapy services were recommended as medically necessary by his treating team. They were correct in this assessment, as the patient did show improvement in functional status with ongoing therapy support. The continued rehabilitation was medically necessary and reasonable for the patient.

Question: What is the background context in this case summary?


Answer:
Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.

Answer: The patient is a male with psoriasis and atopic dermatitis. He also has psoriatic arthritis. He has tried and failed Excimer, Otezla, Tremfya, methotrexate, acitretin, Siliq and Taltz. He has also been on Skyrizi and Sotyktu.

Answer: It is noted that the patient has tried and failed methotrexate.

Context:
Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The health plan's determination is upheld.

The patient is a male with psoriasis and atopic dermatitis. He also has psoriatic arthritis. He has tried and failed Excimer, Otezla, Tremfya, methotrexate, acitretin, Siliq and Taltz. He has also been on Skyrizi and Sotyktu.

Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis.
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults".
It is noted that the patient has tried and failed methotrexate. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Intracranial Hemorrhage

Treatment: Air Ambulance Services (procedure codes A0431, A0436)

The insurer denied coverage for Air Ambulance Services (procedure codes A0431, A0436).

Answer:
The patient is seeking coverage for Air Ambulance Services (procedure codes A0431 and A0436).

Air transportation was requested as the patient's condition was time critical.  The patient's condition required critical life care support and monitoring including electrocardiogram.  The receiving facility provided specialized care, treatment, and diagnostics not available at the referring facility or facility that may have been closer to the scene.  The patient required interventional neurology.  The patient reported that they had become nauseous.  Then they had weakness, dizziness, and vomiting with difficulty speaking.  The patient was brought to the facility.  Imaging of the head showed a hyperdensity consistent with acute hemorrhage within the cerebellum within the midline. There is significant hemorrhage seen surrounding the cerebellar folia bilaterally.  Out of concern that the bleed may be a result of underlying vascular malformation, it was recommended that the patient be transferred to a tertiary facility where they could be observed and if necessary, an angiogram could be performed.  Immediate dispatch was completed for transfer of stroke patient going from St. Luke's Hospital to Westchester Emergency Department (ED) for neurology specialty care that was not available at the sending facility.  The drive time was 65 minutes versus flight time of 17 minutes.  The air transport was notified and dispatched 5 minutes later.

The provider certified that the transfer by air transport was medically necessary

Answer: The patient was suffering from bleeding in the brain

Answer: The services not available at the referring facility.

Answer: Ground transport was estimated to take approximately 65 minutes with transport by air taking

Answer: 17 minutes.

Answer: The patient was suffering from intracranial bleeding potentially requiring advanced airway support

Context:
Diagnosis: Intracranial Hemorrhage

Treatment: Air Ambulance Services (procedure codes A0431, A0436)

The insurer denied coverage for Air Ambulance Services (procedure codes A0431, A0436).

The denial is overturned.

The patient is seeking coverage for Air Ambulance Services (procedure codes A0431 and A0436).

Air transportation was requested as the patient's condition was time critical.  The patient's condition required critical life care support and monitoring including electrocardiogram.  The receiving facility provided specialized care, treatment, and diagnostics not available at the referring facility or facility that may have been closer to the scene.  The patient required interventional neurology.  The patient reported that they had become nauseous.  Then they had weakness, dizziness, and vomiting with difficulty speaking.  The patient was brought to the facility.  Imaging of the head showed a hyperdensity consistent with acute hemorrhage within the cerebellum within the midline. There is significant hemorrhage seen surrounding the cerebellar folia bilaterally.  Out of concern that the bleed may be a result of underlying vascular malformation, it was recommended that the patient be transferred to a tertiary facility where they could be observed and if necessary, an angiogram could be performed.  Immediate dispatch was completed for transfer of stroke patient going from St. Luke's Hospital to Westchester Emergency Department (ED) for neurology specialty care that was not available at the sending facility.  The drive time was 65 minutes versus flight time of 17 minutes.  The air transport was notified and dispatched 5 minutes later.

The provider certified that the transfer by air transport was medically necessary as evidenced by the assigned physician certification statement.  The patient was suffering from bleeding in the brain which required immediate interventional radiology treatment.  The services not available at the referring facility.  Rapid and immediate transport to the receiving facility was medically necessary.  Research has shown that in cases of reduced blood flow to the brain, each minute the patient was without treatment increase the amount of brain tissue death with delay in treatment causing poor outcomes.  Ground transport was estimated to take approximately 65 minutes with transport by air taking just 17 minutes.  Therefore, the ground transport would delay the patient's access to care, threatening their survival, and endangering their health.  Thus, the transport by air ambulance was medically necessary and reasonable.  The air ambulance had all of the equipment and supplies needed to address the patient's needs including specialty critical care providers trained in advanced airway procedures.  The patient was suffering from intracranial bleeding potentially requiring advanced airway support to make another mode of transport contraindicated.  Transport by ground would endanger the patient survival and threaten their health as it would delay access to care and increased out of hospital time.  The patient was suffering from a life-threatening condition.  Air transport was more than 30 minutes faster than transport by ground.

Brain hemorrhage is a medical emergency that requires prompt treatment to prevent complications or death.  The patient had a life-threatening condition which required transport for additional management.  The drive time was more than double the air transport time.  The patient required prompt treatment and ground transport time increased risk for complications and mortality, which made the air transport medically necessary for the patient.

Based on the above, the insurer's denial must be reversed. 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 Air Ambulance Services (procedure codes A0431, A0436) is substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Bile duct obstruction
Treatment: Continued Stay in Skilled Nursing Facility
The insurer denied: Continued Stay in Skilled Nursing Facility

Answer: This adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.

Answer: This patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable.

Context:
Diagnosis: Bile duct obstruction
Treatment: Continued Stay in Skilled Nursing Facility
The insurer denied: Continued Stay in Skilled Nursing Facility
The denial is upheld.

This adult female patient was admitted to an acute inpatient level of care with bile duct obstruction. She underwent exploratory laparotomy with Roux-en-Y-Hepaticojejunostomy. Her past medical history includes cardiomyopathy, depression, hypertension, panic attack, post-traumatic stress disorder (PTSD), and suicidal ideation. The patient was admitted to a skilled nursing facility (SNF) level of care for nursing and rehab services. Her level of function required moderate assist with activities of daily living (ADLs), and transfer. The health plan covered services through day #26. Services after the approved dates are being appealed. As of the last covered day, the patient was tolerating a regular diet. The patient's level of functioning had progressed to supervised with supine to sit and wheelchair; contact guard assistance with lower body dressing and toileting; and stand by assistance with hygiene. The patient is receiving pan management with oral medications.

The requested health service is not medically necessary.

This patient was in an acute inpatient level of care for surgical treatment of bile duct obstruction. She was admitted to a skilled nursing facility level of care. As of day #26, the patient was clinically stable. She was not receiving skilled nursing care. Her level of functioning had improved to supervision, stand by, and contact guard assistance with activities of daily living. Her level of functioning did not require ongoing skilled therapy that could only be provided at a skilled nursing facility level of care. Therefore, the continued stay in the skilled nursing facility was not medically necessary.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Alzheimer's Dementia

Treatment: consumer direct personal assistance service - 80 hours per week

The insurer denied coverage for in consumer direct personal assistance service - 80 hours per week

Answer: The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.

Answer: This is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week

Context:
Diagnosis: Alzheimer's Dementia

Treatment: consumer direct personal assistance service - 80 hours per week

The insurer denied coverage for in consumer direct personal assistance service - 80 hours per week

The denial is overturned

This is an elderly patient with chronic medical problems including hypertension, glaucoma and progressive Alzheimer's dementia. The patient lives with their daughter in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 63 hours per week and the request is for CDPAS 80 hours per week, leading to an external review.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient reportedly requires extensive to maximal assistance for completing Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient also reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Extensive assistance is reportedly needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient's ability to perform activities of daily living (ADLs) and self-sufficiency have declined and deteriorated, respectively, over the prior 90 days.  There have been no reported falls over the prior 90 days.

Based on the documents submitted for review, the patient's medical condition/functional deficits are substantial, progressive and unpredictable as to require the requested increased CDPAS from 63 to 80 hours/day. The letters from the patient's treating medical providers as well as from the daughter were particularly persuasive.  Again, based on the documented submitted for review, the patient's health and safety are more appropriately provided and maintained at home with the requested increase CDPAS of 80 hours/week.

Based on the above, the insurer's denial must be reversed. 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 in consumer direct personal assistance service - 80 hours per week is substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Low back surgery due to back and bilateral leg pain.
Treatment: Full hospital admission.
The insurer denied the full hospital admission.

Answer: The patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home.

Answer: this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE)

Context:
Diagnosis: Low back surgery due to back and bilateral leg pain.
Treatment: Full hospital admission.
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home.

The inpatient hospital admission was medically necessary. Lumbar laminectomy is typically performed as an outpatient. Unfortunately, as can happen in surgery, this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE) which can slow down physical therapy progress. Given the patient's need to remain in the hospital for more than 2 midnights, her appropriate level of care would be inpatient. The patient was not able to be safely discharged prior to postoperative day (POD) 7. Her care could not have been rendered at a lower level of care for the duration of her stay.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Rheumatoid Arthritis
Treatment: Orencia
The insurer denied Orencia.

Answer: This is a female patient with rheumatoid arthritis (RA). Prior treatments included Cimzia, intravenous (IV) Orencia, subcutaneous (SQ) Orencia and Plaquenil (stopped due to gastrointestinal (GI) side effects). The patient has been on Orencia in the past and her provider would like to re-start it. Subcutaneous (SQ) Orencia is being denied by the health plan as the preferred formulary drugs have not been tried. The primary preferred formulary drugs, include Humira, Hyrimoz, Rinvoq and Xeljanz. The secondary preferred drug is Kevzara. Of note, the patient has a latex allergy. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Context:
Diagnosis: Rheumatoid Arthritis
Treatment: Orencia
The insurer denied Orencia.
The determination is upheld.

This is a female patient with rheumatoid arthritis (RA). Prior treatments included Cimzia, intravenous (IV) Orencia, subcutaneous (SQ) Orencia and Plaquenil (stopped due to gastrointestinal (GI) side effects). The patient has been on Orencia in the past and her provider would like to re-start it. Subcutaneous (SQ) Orencia is being denied by the health plan as the preferred formulary drugs have not been tried. The primary preferred formulary drugs, include Humira, Hyrimoz, Rinvoq and Xeljanz. The secondary preferred drug is Kevzara. Of note, the patient has a latex allergy. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

All formulary medications would be as effective for the treatment of RA. However, Humira and hyrimoz (Humira biosimilar) are not options as the patient has a latex allergy and the needle cover of prefilled syringe and autoinjector of these medications may contain latex. Xeljanz, Rinvoq and Kevzara do not contain latex and thus there is no medical reason the patient cannot try one of these preferred medications as they are indicated for the treatment of RA. For example, as published in N Engl J Med in 2012, "in patients with active rheumatoid arthritis, tofacitinib monotherapy was associated with reductions in signs and symptoms of rheumatoid arthritis and improvement in physical function". Moreover, a paper in Arthritis Rheumatol in 2017 concluded that "sarilumab 150 milligrams (mg) and sarilumab 200 mg every 2 weeks plus conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) improved the signs and symptoms of RA and physical function in patients with an inadequate response or intolerance to anti-tumor necrosis factor (TNF) agents. Safety data were consistent with interleukin-6 receptor blockade and the known safety profile of sarilumab". Like Orencia, Xeljanz, Rinvoq and Kevzara would need to be stopped when pregnant as well. As stated, Humira is not an option due to the patient's latex allergy. There is no reason the patient cannot try one of the latex free drugs on the health plan's formulary.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Toenail fungus
Treatment: Jublia
The insurer denied Jublia.

Answer: The patient is a female who was treated for toenail fungus. She was treated with ciclopirox topical medication. She was also given Itraconazole. She had been treated by a different podiatrist and tried Formula 3 and terbinafine orally with minimal improvement. The patient was recommended and prescribed Jublia. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Answer: The patient has tried terbinafine tablets, itraconazole tablets, and ciclopirox solution.

Context:
Diagnosis: Toenail fungus
Treatment: Jublia
The insurer denied Jublia.
The determination is upheld.

The patient is a female who was treated for toenail fungus. She was treated with ciclopirox topical medication. She was also given Itraconazole. She had been treated by a different podiatrist and tried Formula 3 and terbinafine orally with minimal improvement. The patient was recommended and prescribed Jublia. At issue is whether the formulary drugs will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

Based on the review of medical records, standards of care, and literature, all of the formulary drugs (Kerydin, tavaborole solution, terbinafine tablets, itraconazole tablets and ciclopirox) are known to be as effective as or more effective then the non-formulary drug. The patient has tried terbinafine tablets, itraconazole tablets, and ciclopirox solution. However, the patient does not have documentation of trying Kerydin or tavaborole solution.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

Answer: The patient presented to the hospital for evaluation of altered mental status and loss of consciousness concerning for seizure or syncope.  The patient had a history of seizures.  The patient described an aura sensation and believed that they had seizures the previous day and today.  The patient described racing heart and then waking up on the ground.  It was unclear if the patient had focal or generalized seizures in the past.  The patient was on Fycompa and Briviact and was adherent with the medications.  The patient reported that they would typically get aura sensation prior to seizure around the time of their period.  The patient reported that they felt that they were about to get their period.  The patient stated that they felt that they had a third episode with emergency medical services.  It was indicated that the patient nodded their head and there was no generalized tonic-clonic activity.  The patient's neurologist was called.  The provider stated that the patient has suspected psychogenic seizures, but the patient had been discharged from their clinic as the patient was no longer following the recommendations.  The patient was given the current medications but advised to find a new provider.  The patient had continuous electroencephalogram for 3 days and had some events that were captured on video but not associated with any electrographic seizure activity.  The patient had a history of real epilepsy in the past, but it was now suspected to be more psychogenic.  There were episodes in the past in which the patient stated that they could not walk but demonstrated full strength on exam.  While in the emergency department, the patient had an episode of possible seizure that lasted less than 1 minute and broke spontaneously.  Ativan was given prophylactically after the seizure broke.  The patient had turning of the head to the right, tense body, and was not responsive.  There was slight jerking of the leg but no overt tonic-clonic jerking motion.  There was slight right gaze deviation during the episode.  After the episode, the patient was awake and talking but had some twitching around the eye which resolved in less than 1 minute.  There was consideration for admission for syncope versus seizure.  Vital signs noted temperature of 98.7 Fahrenheit, heart rate of 108, and blood pressure 106/68.  Laboratory testing noted elevated troponin of 12.2.  Electrocardiogram demonstrated normal sinus rhythm.  Computed tomography (CT) of the head was unremarkable.  The urine drug screen was negative.  The patient was treated with intravenous (IV) fluid, Keppra, and Ativan.

Context:
Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented to the hospital for evaluation of altered mental status and loss of consciousness concerning for seizure or syncope.  The patient had a history of seizures.  The patient described an aura sensation and believed that they had seizures the previous day and today.  The patient described racing heart and then waking up on the ground.  It was unclear if the patient had focal or generalized seizures in the past.  The patient was on Fycompa and Briviact and was adherent with the medications.  The patient reported that they would typically get aura sensation prior to seizure around the time of their period.  The patient reported that they felt that they were about to get their period.  The patient stated that they felt that they had a third episode with emergency medical services.  It was indicated that the patient nodded their head and there was no generalized tonic-clonic activity.  The patient's neurologist was called.  The provider stated that the patient has suspected psychogenic seizures, but the patient had been discharged from their clinic as the patient was no longer following the recommendations.  The patient was given the current medications but advised to find a new provider.  The patient had continuous electroencephalogram for 3 days and had some events that were captured on video but not associated with any electrographic seizure activity.  The patient had a history of real epilepsy in the past, but it was now suspected to be more psychogenic.  There were episodes in the past in which the patient stated that they could not walk but demonstrated full strength on exam.  While in the emergency department, the patient had an episode of possible seizure that lasted less than 1 minute and broke spontaneously.  Ativan was given prophylactically after the seizure broke.  The patient had turning of the head to the right, tense body, and was not responsive.  There was slight jerking of the leg but no overt tonic-clonic jerking motion.  There was slight right gaze deviation during the episode.  After the episode, the patient was awake and talking but had some twitching around the eye which resolved in less than 1 minute.  There was consideration for admission for syncope versus seizure.  Vital signs noted temperature of 98.7 Fahrenheit, heart rate of 108, and blood pressure 106/68.  Laboratory testing noted elevated troponin of 12.2.  Electrocardiogram demonstrated normal sinus rhythm.  Computed tomography (CT) of the head was unremarkable.  The urine drug screen was negative.  The patient was treated with intravenous (IV) fluid, Keppra, and Ativan.

However, the documentation did not detail that there was hemodynamic instability that was not readily corrected by appropriate treatment, status epilepticus, that there was a brain disorder such as tumor, edema, trauma, or encephalitis that required monitoring or intervention available only at inpatient level of care, that the etiology was related to factors such as drug toxicity, withdrawal, or nonadherence that required monitoring or intervention available only at inpatient level of care, that there was altered mental status that was severe or persistent, that there was new focal neurologic deficit, that there was a metabolic disorder that persisted despite observation care, that there was recurrent seizure without known seizure disorder, that the seizure was a different seizure type than previously known, or that there was baseline of infrequent seizure and the recurrence was not thought to be due to readily modifiable etiology.

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 an inpatient admission is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Duchenne Muscular Dystrophy

Treatment: 39 Home Health Visits

The insurer denied coverage for 39 Home Health Visits

Answer: This is a patient diagnosed with Duchenne Muscular Dystrophy (DMD). The patient is dependent for activities of daily living (ADL) and non-ambulatory. Under review is the medical necessity of occupational therapy (OT) 39 home health visits.

Answer: According to the notes, the patient "has been going for physical therapy (PT)/OT 3 times a week."  The provider also includes medical literature regarding the diagnosis, management and rehabilitation of DMD (1, 2).

Context:
Diagnosis: Duchenne Muscular Dystrophy

Treatment: 39 Home Health Visits

The insurer denied coverage for 39 Home Health Visits

The denial is upheld

This is a patient diagnosed with Duchenne Muscular Dystrophy (DMD). The patient is dependent for activities of daily living (ADL) and non-ambulatory. Under review is the medical necessity of occupational therapy (OT) 39 home health visits.

The clinical records submitted are insufficient to support the medical necessity for the requested OT services. The letter from the patient's treating physician describing the patient's underlying diagnosis (DMD), limited functional ability, and reported medical necessity of physical and occupational therapy was reviewed. Also reviewed were the office visit notes and "Video-Visit note". According to the notes, the patient "has been going for physical therapy (PT)/OT 3 times a week."  The provider also includes medical literature regarding the diagnosis, management and rehabilitation of DMD (1, 2). However, the actual PT/OT notes, which require evidence of continued and sustained functional improvement, were not included for review.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies and boards. All decisions are evidenced based.

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 occupational therapy 39 home health visits is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Malocclusion

Treatment: D8080 Braces and D8670 monthly visits

The insurer denied coverage for D8080 Braces and D8670 monthly visits

Answer: Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, appeal letter the patient's orthodontist with references, as well as insurer correspondence, it appears that this patient with muscular dystrophy, presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including mandibular protrusion, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 36 total points to support orthodontic care. 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 7 points by internal reviewers. The orthodontist is appealing the decision.

Context:
Diagnosis: Malocclusion

Treatment: D8080 Braces and D8670 monthly visits

The insurer denied coverage for D8080 Braces and D8670 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, orthodontist treatment records, appeal letter the patient's orthodontist with references, as well as insurer correspondence, it appears that this patient with muscular dystrophy, presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including mandibular protrusion, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 36 total points to support orthodontic care. 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 7 points by internal reviewers. The orthodontist is appealing the decision.

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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index. Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 36 points to justify orthodontic care. The reviewer concurs with the index completed by the insurer attaining a total of 7 points on the HLD index (2 overjet, 2 overbite, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Deviation 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.

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 D8080 Braces and D8670 monthly visits is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Multiple Sclerosis

Treatment: Subacute rehabilitation

The insurer denied coverage for subacute rehabilitation

Answer: This is a patient with diagnosed multiple sclerosis and more recently urinary tract infection(s).  The patient's ability to perform activities of daily living (ADLs) and functional mobility has gradually declined.  The patient was admitted (from home) to the skilled nursing facility (SNF).  The patient received physical and occupational therapy.  Under review is the medical necessity for subacute rehabilitation.

Answer:
The patient presented from home to the skilled nursing facility (SNF).  Upon presentation, the patient required a foley urinary catheter and drainage bag.  The patient's ability to perform activities of daily living and functional mobility ranged from maximal assistance to total dependence.

Over the next several weeks, the foley catheter was eventually removed, and the patient was able to urinate on their own.

Answer: the patient's ability to perform activities of daily living and functional mobility had demonstrated only limited improvement.  According to the physical therapy notes, the patient was unable to ambulate with or without an assistive device.  The patient required the assistance of 2 people, an Eva support walker and a wheelchair followed close behind; being upright for approximately 15 feet.  The patient also required 2 people to transfer from sitting to standing.  A similar lack of progress was documented by the occupational therapist.  The patient continued to require moderate to maximal assistance for bathing, dressing and toileting activities.

Context:
Diagnosis: Multiple Sclerosis

Treatment: Subacute rehabilitation

The insurer denied coverage for subacute rehabilitation

The denial is upheld

This is a patient with diagnosed multiple sclerosis and more recently urinary tract infection(s).  The patient's ability to perform activities of daily living (ADLs) and functional mobility has gradually declined.  The patient was admitted (from home) to the skilled nursing facility (SNF).  The patient received physical and occupational therapy.  Under review is the medical necessity for subacute rehabilitation.

The submitted SNF records do not support that the patient continued to be an appropriate candidate for the subacute rehabilitation SNF level of care during the time period under review (1, 2, 3).  The patient presented from home to the skilled nursing facility (SNF).  Upon presentation, the patient required a foley urinary catheter and drainage bag.  The patient's ability to perform activities of daily living and functional mobility ranged from maximal assistance to total dependence.

Over the next several weeks, the foley catheter was eventually removed, and the patient was able to urinate on their own.  Unfortunately, the patient's ability to perform activities of daily living and functional mobility had demonstrated only limited improvement.  According to the physical therapy notes, the patient was unable to ambulate with or without an assistive device.  The patient required the assistance of 2 people, an Eva support walker and a wheelchair followed close behind; being upright for approximately 15 feet.  The patient also required 2 people to transfer from sitting to standing.  A similar lack of progress was documented by the occupational therapist.  The patient continued to require moderate to maximal assistance for bathing, dressing and toileting activities. Subsequent treatment for the time period under review could have been safely provided at a lower level of care (e.g., long term care or home care with visiting therapy services). There were also no other specific acute medical or complicated nursing issues that warranted continued subacute rehabilitation level of care for the time period under review.

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 subacute is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Diabetes, thrombocytopenia, dementia.
Treatment: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In).
The insurer denied: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In).

Answer: This elderly female patient has medical conditions that include hypertension, diabetes, hypothyroidism, anemia, and thrombocytopenia. She lives alone. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. The Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient's daughter administers medications and assists as needed. The patient has occasional bowel and bladder incontinence. She had a fall 2 months ago due to dizziness. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with her cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. A letter from the Provider reports the patient has dementia that impacts her ability to perform activities of daily living (ADLs).

Answer: she wanders when alone. The patient has need for frequent toileting and has incontinence. She is at risk for falling.

Answer: This patient has multiple chronic conditions. She lives alone. Her daughter provides informal support. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows the patient has moderately impaired cognition and requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with the patient's cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. The appeal statement supports the patient needs assistance with all activities of daily living. She requires unscheduled assistance with toileting due to urinary frequency and incontinence. Additional assistance is requested for the patient's safety due to in-house accidents and wandering.

Context:
Diagnosis: Diabetes, thrombocytopenia, dementia.
Treatment: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In).
The insurer denied: Increase Home/Personal Care Level 2 to 24 Hours per Day (Live-In).
The denial is overturned.

This elderly female patient has medical conditions that include hypertension, diabetes, hypothyroidism, anemia, and thrombocytopenia. She lives alone. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. The Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances and medications; extensive assistance with bathing, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. The patient's daughter administers medications and assists as needed. The patient has occasional bowel and bladder incontinence. She had a fall 2 months ago due to dizziness. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with her cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. A letter from the Provider reports the patient has dementia that impacts her ability to perform activities of daily living (ADLs). Additional hours are needed for prevent onset of disability, to prevent in-house accidents as she will turn the stove on, and her safety because she wanders when alone. The patient has need for frequent toileting and has incontinence. She is at risk for falling.

The requested health service is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding. This patient has multiple chronic conditions. She lives alone. Her daughter provides informal support. The denial of an increase in home/personal care level 2 to 24 hours per day (live-in) is being appealed. The health plan approved 56 hours per week. Uniform Assessment System (UAS) evaluation completed nearly 2 months ago shows the patient has moderately impaired cognition and requires extensive assistance to total dependence with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with the patient's cognition and functioning with personal hygiene, dressing, toileting, walking, locomotion, bed mobility, and eating. The appeal statement supports the patient needs assistance with all activities of daily living. She requires unscheduled assistance with toileting due to urinary frequency and incontinence. Additional assistance is requested for the patient's safety due to in-house accidents and wandering. The information provided shows that this patient has significant limitations in cognition and functioning that have progressed over Uniform Assessment System evaluations. Her limitations and need for frequent assistance with unscheduled toileting cannot be met with the approved personal care services of 56 hours per week. The proposed increase home /personal care personal care services to 24 hours per day (live-in) is medically indicated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Obesity and pre-diabetes.

Treatment: Wegovy 2.4 mg/0.75 ml, pen injectors.

The insurer denied coverage for Wegovy 2.4 mg/0.75 ml, pen injectors.

Answer:
This is a patient diagnosed with obesity. This request is for Wegovy. As per the visit note, the patient had pre-diabetes with a hemoglobin A1C of 5.4%, dyslipidemia, obstructive sleep apnea (OSA), and hypertension (HTN). The patient is on Ozempic 2 milligrams (mg) weekly. The patient is noticing with Ozempic some stomach cramps and loose stools.

The patient's starting weight was 293 pounds (lbs.). On subsequent visits, the patient's weights and body mass index (BMI) were: 262.4 lbs., BMI 33.7; 262.8 lbs., BMI 33.7; and most recently, 258 lbs., BMI 33.1.

Answer: The patient had a BMI of 33.1 recently

Context:
Diagnosis: Obesity and pre-diabetes.

Treatment: Wegovy 2.4 mg/0.75 ml, pen injectors.

The insurer denied coverage for Wegovy 2.4 mg/0.75 ml, pen injectors.

The denial is upheld.

This is a patient diagnosed with obesity. This request is for Wegovy. As per the visit note, the patient had pre-diabetes with a hemoglobin A1C of 5.4%, dyslipidemia, obstructive sleep apnea (OSA), and hypertension (HTN). The patient is on Ozempic 2 milligrams (mg) weekly. The patient is noticing with Ozempic some stomach cramps and loose stools.

The patient's starting weight was 293 pounds (lbs.). On subsequent visits, the patient's weights and body mass index (BMI) were: 262.4 lbs., BMI 33.7; 262.8 lbs., BMI 33.7; and most recently, 258 lbs., BMI 33.1.

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist that is approved by Food and Drug Administration (FDA) in treating type II diabetes and obesity. Recent studies published in major peer-reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for treating obesity in the form of Wegovy. The standard of care based on multiple societal guidelines requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia.

The patient had a BMI of 33.1 recently; however, there is no documentation of participation in lifestyle modifications.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for Wegovy 2.4 milligrams (mg)/0.75 milliliters (ml), pen injectors services is not substantiated.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Decreased mobility.
Treatment: Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week.
The insurer denied Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week.

Answer: This is a case review for a male with medical history notable for mobility issues, incontinence, and end stage renal disease. The patient and his care team requested Personal Care Services.

Answer: The most recent Uniform Assessment System (UAS) functional assessment reports that there was no significant functional decline, however in the text of the assessment it does report that his functional status has been worsening and that he does require personal care assistance with all activities of daily living.

Context:
Diagnosis: Decreased mobility.
Treatment: Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week.
The insurer denied Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week.
The health plan's determination is overturned.

This is a case review for a male with medical history notable for mobility issues, incontinence, and end stage renal disease. The patient and his care team requested Personal Care Services.

The Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week service is medically necessary for this patient.
The patient requires personal care assistance for nearly all activities of daily living, including ambulating, toileting, and transfers. Given that some of these personal care needs will be unscheduled throughout the day, the requested increase from 7 to 11 hours per day is reasonable and appropriate to meet the patient's functional needs. The most recent Uniform Assessment System (UAS) functional assessment reports that there was no significant functional decline, however in the text of the assessment it does report that his functional status has been worsening and that he does require personal care assistance with all activities of daily living. The increase in hours is therefore medically necessary and appropriate for the patient. His fall in the previous 30 days before the assessment is evidence of unmet personal care needs, as he requires assistance with ambulation and further attempts to do so without assistance could result in additional injuries.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.
The insurer denied  Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.

Answer:
The patient is a female with a medical history notable for Alzheimer's dementia. The patient was approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care worker services.
The patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has deteriorated over the last two to three months. She has been falling while walking to the bathroom at night and also while getting out of bed. She has had inappropriate hygiene overnight due to a lack of personal care support. She is no longer able to care for herself independently and requires constant assistance.
A Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place during the visit. They noted that she has worsening sundowning and confusion at night. She is occasionally incontinent of urine and infrequently incontinent of stool. Compared to an assessment performed approximately 3 months prior, the patient showed a significant decline in level of function for activities of daily living. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.

Context:
Diagnosis: Alzheimer's dementia.
Treatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.
The insurer denied  Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.
The determination is overturned in part.

The patient is a female with a medical history notable for Alzheimer's dementia. The patient was approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care worker services.
The patient's physician provided a letter of support for this appeal. The letter states that the patient's condition has deteriorated over the last two to three months. She has been falling while walking to the bathroom at night and also while getting out of bed. She has had inappropriate hygiene overnight due to a lack of personal care support. She is no longer able to care for herself independently and requires constant assistance.
A Uniform Assessment System (UAS) was completed. The patient lives alone in a two-bedroom apartment. She was alert and oriented to person and place during the visit. They noted that she has worsening sundowning and confusion at night. She is occasionally incontinent of urine and infrequently incontinent of stool. Compared to an assessment performed approximately 3 months prior, the patient showed a significant decline in level of function for activities of daily living. At issue is the medical necessity of Personal Care Worker (PCW) services 7 days per week, 12 hours per day times (x) 2 split shifts continuous by more than one person; 168 hours per week.

The services are medically necessary in part. The requested health service of Personal Care Worker (PCW) services 7 days per week, 12 hours per day x 2 split shifts continuous by more than one person; 168 hours per week has not been demonstrated to be medically necessary for this patient. Personal Care Worker (PCW) services 7 days per week, 24 hours per day live-in is medically necessary for this patient.
The patient requires assistance with essentially all activities of daily living, including toileting, transfers, and ambulation. Because of this, the patient will have personal care needs that are continuous and unscheduled throughout the day and occasionally at night as well. Her recent falls are evidence of unmet personal care needs. Therefore, it is medically necessary that the patient receive 24-hour per day personal care assistance.
There is insufficient documentation that the patient requires 24-hour split shift personal care assistance. Split shift personal care is medically necessary for patients whose personal care needs have been demonstrated to be continuous overnight and of such frequency that a live-in personal care assistant would not be able to receive adequate rest at night. There were no overnight care logs provided for review. The patient is not being treated for a pressure ulcer that requires frequent turning and repositioning. Supervision and safety monitoring alone is not an allowable personal care function, and 24-hour split shift care cannot be authorized merely to provide supervision. However, a live-in personal care aide would be medically appropriate to address any care needs such as toileting which would occur infrequently in the evening and night time.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Decrease in kidney function
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission

Answer: The patient is an adult female who was admitted for worsening kidney function on outpatient labs with hyperkalemia. She was evaluated by nephrology service and was started on intravenous fluid and treated with Lokelma for elevated potassium level. The patient was noted to have adequate urine output and her creatinine was trending down appropriately, which was consistent with prerenal azotemia. Her condition stabilized and she was discharged on day #4.

Answer: The patient was admitted for dehydration and was noted to have elevated creatinine

Answer: This patient's kidney function improved back to baseline in 48 hours

Answer: she was hemodynamically stable and was able to tolerate an oral diet

Context:
Diagnosis: Decrease in kidney function
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who was admitted for worsening kidney function on outpatient labs with hyperkalemia. She was evaluated by nephrology service and was started on intravenous fluid and treated with Lokelma for elevated potassium level. The patient was noted to have adequate urine output and her creatinine was trending down appropriately, which was consistent with prerenal azotemia. Her condition stabilized and she was discharged on day #4.

The requested health service was not medically necessary.

The patient was admitted for dehydration and was noted to have elevated creatinine; however, the patient's acute kidney injury could have been treated safely under a lower level of care. The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent acute tubular necrosis. This patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis, which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy. In addition, she was hemodynamically stable and was able to tolerate an oral diet. When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, she had no requirements for inpatient level of care. Therefore, the requested health service was not medically necessary.

Question: What is the background context in this case summary?


Answer:
Diagnosis: Crohn's disease and celiac disease
Treatment: Rinvoq
The insurer denied Rinvoq

Answer: The patient is a female with Crohn's disease and celiac disease. She has failed 6-mercaptopurine, Remicade, Entyvio, and Stelara (started in 2018) every 4 weeks. While on Stelara every 4 weeks, she had improvement, but persistent rectal disease. She had improvement in rectal disease with the addition of Rinvoq.

Answer: The patient's disease is severe and diagnosed at a young age, with history of multiple medication failures, including all primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease.

Context:
Diagnosis: Crohn's disease and celiac disease
Treatment: Rinvoq
The insurer denied Rinvoq
The health plan's determination is overturned.

The patient is a female with Crohn's disease and celiac disease. She has failed 6-mercaptopurine, Remicade, Entyvio, and Stelara (started in 2018) every 4 weeks. While on Stelara every 4 weeks, she had improvement, but persistent rectal disease. She had improvement in rectal disease with the addition of Rinvoq.

Rinvoq is medically necessary for this patient.
The current medical literature supports the request for Rinvoq for the treatment of Crohn's disease. The patient's disease is severe and diagnosed at a young age, with history of multiple medication failures, including all primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease. Several studies have assessed the use of multiple therapies concurrently, including biologic therapy (such as Stelara) with small molecule therapy (such as Rinvoq). In aggregate, no significant safety issues were attributed to combination therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy. Rinvoq is Food and Drug Administration (FDA) -approved for the treatment of Crohn's disease, and has demonstrated safety and efficacy.

Question: What is the background context in this case summary?