Answer: A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes.

Answer: this patient

Answer: presented with lymphadenopathy of unknown origin

Context:
Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the Epstein-Barr virus is the main etiology of infectious mononucleosis (IM) syndrome that is characterized by fever, sore throat, and lymph adenopathy. Since this virus could be associated with a number of malignancies, some hematologic disorders, and chronic fatigue syndrome, identification of IM is of importance.  The majority of the human adult population is infected with EBV. Usually the infection is well tolerated without any further symptoms after primary infection. In some patients with infectious mononucleosis, or in some who had an infection in their past, it may be important to diagnose symptomatic disease or differentiate infectious mononucleosis from other conditions. In these cases, serological methods, i.e., immunofluorescence, ELISA, or Western blot, are the methods of choice to come to an unequivocal diagnostic conclusion, while the detection and quantification of viral DNA through PCR plays a minor role. ELISA could be applied as a first and preliminary diagnostic test for IM. In addition, this test could be applied in various phases of the disease with a higher sensitivity comparing to PCR. In individuals where EBV infection is associated or causally linked with autoimmune or malignant disease or in patients who have been bone marrow or solid organ transplanted, or in patients with severe immune-suppression, prolonged EBV primary infection or EBV reactivation from latency may be a serious and life-threatening complication. As such, determining the serostatus correctly is important for these patients. However, in this patients case, there was no documentation that this patient had immunosuppression or that she was a transplant patient. In sum, for this patient who presented with lymphadenopathy of unknown origin, PCR testing provided on 5/30/17, was not likely to have been superior over other standard methods of evaluating her medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.

Answer: In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission.

Context:
Summary Reviewer

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the records for the medical necessity of the services at issue in this clinical setting.  Evidence-based assessments are indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The medical literature states that children should be treated in the setting that is least restrictive and disruptive to their lives. More restrictive facilities, like inpatient or residential treatment, are indicated in emergencies or when patients are not responding to efforts at outpatient treatment. In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible to maintain and foster natural supports. This patient did not appear to have adequate treatment progress, and it would not have been safe to treat the patient in a less restrictive setting. The RTC was likely the least restrictive safe setting for this patient after having failed the PHP. Therefore, the mental health residential treatment center services from 11/17/16 through 12/10/16 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.

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


Answer: A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.

Context:
Summary Reviewer 1

A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  There is a lack of prospective controlled data to support random measurement of Remicade/Remicade antibody levels.  The concept of targeted drug level monitoring is supported for several classes of drugs.  However, evidence is lacking for biologic agents in the treatment of this patients condition.  There are multiple variables which drug level monitoring does not consider, thus making this line of testing suboptimal.  For example, the optimal trough level of Remicade remains unknown and likely varies from individual to individual based on unique pharmacokinetics.  Additionally, tissue levels of drug also play an important role.  Therefore, Anser IFX testing performed on 8/17/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.

Context:
Summary Reviewer 2

A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser IFX testing performed on 8/17/15 was not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.

Context:
Summary Reviewer 3

A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the management of ulcerative colitis using Anser IFX testing has not been standardized, and standardized recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed. The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Per the clinical literature, Anser IFX testing performed on 8/17/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.

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


Answer: This case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.

Answer: Diagnosis: Clogged feeding tube

Answer: Treatment: Inpatient admission, interventional procedure

Answer: The insurer denied the admission.

Context:
Diagnosis: Clogged feeding tube

Treatment: Inpatient admission, interventional procedure

The insurer denied the admission. The denial was upheld.

This case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.

The records failed to support that the patient was unstable or had findings to support the need for inpatient admission. The patient could have undergone the procedure as an outpatient or been placed on observation status.

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


Answer: This patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.

Answer: Diagnosis: Lactic acidosis

Answer: Treatment: inpatient hospital admission

Answer: The insurer denied inpatient hospital admission.

Answer: He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled

Answer: This patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved.

Context:
Diagnosis: Lactic acidosis

Treatment: inpatient hospital admission

The insurer denied inpatient hospital admission. The denial was upheld.

This patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.

According to Milliman Care Guidelines (MCG), clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe electrolyte abnormalities, high fevers and acute renal failure. The patient did not have these conditions. He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled but the patient did not have diabetic ketoacidosis.

This patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved. IV hydration, Reglan, and Pepcid could have been given with observation status. The patient responded well to the ER treatment. If antibiotics were felt to be needed, they could have been continued orally as an outpatient. He did not meet MCG guidelines for admission for vomiting. The healthcare plan acted reasonably and with sound medical judgment. Inpatient hospital services were not medically necessary.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.

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


Answer: The patient failed 1% testosterone gel and Fortesta.  He has benefited from the requested formulation.

Answer: Diagnosis:  Testicular hypofunction

Answer: Treatment:  Formulary exception for testosterone gel

Answer: The patient is a male diagnosed with Hypogonadism.  This request is for Testosterone gel.  As reported, he used testosterone 1 % in the past and had treatment failure.  He had Pituitary adenoma s/p (status post) resection in the past.  In past he has blurry vision and headache diagnosed with Tolosa Hunt syndrome.  He completed testosterone XRT.  The formulary alternatives include testosterone transdermal gel 10 mg per actuation 2% and testosterone cypionate and testosterone enanthate.  He also tried Fortesta transdermal gel 10 mg per actuation.  He benefited from the requested formulation testosterone 1% 50mg/5g.

Answer: The patient's testosterone was 141 (264-916, median 590); free testosterone was 6.4 (6.6-18.1, median 12.35).

Answer: Previously the patient's testosterone was 232 (264-916, median 590); Estradiol was 34.6.

Answer: Previous to the above, the patient's testosterone was 444.33 (300-1080, median 690); PSA (prostate specific antigen) was 1.74 (0-4).

Answer: Previous to that the patient's testosterone was 211.74 (300-1080, median 690); SHBG (Sex Hormone Binding Globulin) was 27; LH (luteinizing hormone) was <0.50; IGF1 (insulin-like growth factor 1) was 125; GH (growth hormone) was 0.08; FSH (follicle stimulating hormone) was 0.6; ACTH (adrenocorticotropic hormone) was 113; Free testosterone was 5.1 (4-29 median 16); testosterone Bioavailable was 96 (77-367, median 222) .

Answer: This patient has two documented low testosterone levels, with non-elevated LH levels in the setting of a history of pituitary surgery.

Context:
Diagnosis:  Testicular hypofunction
Treatment:  Formulary exception for testosterone gel
The health plan should cover the Formulary exception for Testosterone gel.

The patient is a male diagnosed with Hypogonadism.  This request is for Testosterone gel.  As reported, he used testosterone 1 % in the past and had treatment failure.  He had Pituitary adenoma s/p (status post) resection in the past.  In past he has blurry vision and headache diagnosed with Tolosa Hunt syndrome.  He completed testosterone XRT.  The formulary alternatives include testosterone transdermal gel 10 mg per actuation 2% and testosterone cypionate and testosterone enanthate.  He also tried Fortesta transdermal gel 10 mg per actuation.  He benefited from the requested formulation testosterone 1% 50mg/5g.

The patient's testosterone was 141 (264-916, median 590); free testosterone was 6.4 (6.6-18.1, median 12.35).

Previously the patient's testosterone was 232 (264-916, median 590); Estradiol was 34.6.

Previous to the above, the patient's testosterone was 444.33 (300-1080, median 690); PSA (prostate specific antigen) was 1.74 (0-4).

Previous to that the patient's testosterone was 211.74 (300-1080, median 690); SHBG (Sex Hormone Binding Globulin) was 27; LH (luteinizing hormone) was <0.50; IGF1 (insulin-like growth factor 1) was 125; GH (growth hormone) was 0.08; FSH (follicle stimulating hormone) was 0.6; ACTH (adrenocorticotropic hormone) was 113; Free testosterone was 5.1 (4-29 median 16); testosterone Bioavailable was 96 (77-367, median 222) .

The American association of clinical endocrinologists and the Endocrine society recommendations require documentation of two low morning testosterone or free testosterone levels (1, 2).  The diagnosis of hypogonadotropic or primary hypogonadism is made with a low testosterone, or free testosterone (2, 3).  The causes of acquired hypogonadotropic hypogonadism are the following:  1)  structural (tumors, infiltrative lesions, infarction, head trauma), and 2)  functional (hyperprolactinemia, hypercortisolism, obesity, chronic systemic disease) (4).
Since the majority of causes involve abnormalities of the pituitary or hypothalamus, an MRI is indicated to rule out structural lesions in these patients (3).  MRI is indicated in this group of patients when they are <50 for all patients with a low testosterone and a normal LH or an elevated prolactin (5-8).  In older men, an MRI is indicated when there is a very low testosterone <150ng/dl and a normal LH or an elevated prolactin or with visual changes or headaches.  Obesity is a known cause of hypogonadotropic hypogonadism (5).  The diagnosis of hypogonadism is made using a low testosterone and an elevated LH and FSH (primary) or low or normal LH (secondary).

The endocrine society criteria recommend adjusting testosterone dosing to keep the testosterone level in the middle of the normal range.

"We suggest aiming at achieving serum testosterone levels during treatment in the mid-normal range."

The endocrine society criteria also recommend that testosterone be adjusted with the patient symptoms in mind.

This patient has two documented low testosterone levels, with non-elevated LH levels in the setting of a history of pituitary surgery.  Based on this, he meets accepted criteria for treatment with testosterone.

The patient failed 1% testosterone gel and Fortesta.  He has benefited from the requested formulation.  Given the fact that the patient already failed two forms of testosterone gel, and the fact that he benefited from the requested formulation, the health plan should cover the requested treatment.

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


Answer: This is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities.

Answer: Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)

Answer: Treatment: Livalo 2 milligrams OR tablets

Answer: The insurer denied Livalo 2 milligrams OR tablets.

Context:
Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)

Treatment: Livalo 2 milligrams OR tablets

The insurer denied Livalo 2 milligrams OR tablets. The denial was upheld.

This is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities.

All FDA-approved statins have been shown to reduce cardiovascular risk; the magnitude of the reduction is related to the magnitude of LDL-C lowering.  Atorvastatin and rosuvastatin at their highest approved doses are the most effective in lowering LDL-C levels and their beneficial effects on clinical outcomes are well-documented.  All of the statins except pitavastatin and pitavastatin magnesium are available generically.  Dosage adjustments are not required with atorvastatin or fluvastatin in patients with severe renal impairment.  Pravastatin, rosuvastatin, and pitavastatin are not metabolized by CYP isozymes and are less likely to interact with other drugs.

Oral pitavastatin (Livalo) is a competitive HMG-CoA reductase for the reduction of elevated total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia. Pitavastatin is an effective treatment option in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia, including those at risk of developing type 2 diabetes.

The carrier's denial of coverage for Livalo 2 milligrams OR tablets is upheld.  The medical necessity is not substantiated.

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


Answer: The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.

Answer: The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.

Answer: The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.

Context:
The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.

The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.

The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient substance abuse treatment  is not medically necessary for this patient.

The proposed treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's alcohol use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.

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


Answer: This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.

Answer: The patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day.

Context:
This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.
The patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day.
The health plan's determination is overturned.
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms and general medical conditions associated with laboratory abnormalities and high risk for withdrawal complications such as seizures. Withdraw symptoms were managed with an Ativan protocol requiring monitoring, as well as comfort medications and vitamin replacement therapy, and continuation of medications to manage his general medical illnesses. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.

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


Answer: The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.

Answer: he has lived as a male and been on hormone therapy for over a year

Context:
The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.

The health plan's determination is overturned.

Yes, the bilateral mastectomy and nipple reconstruction are medically necessary for this patient.

The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus. The most recent standards published in 2011 are version 7 and are the current standards of care applied by physicians and surgeons worldwide. Prior to any treatment the criteria requirements are diagnostic and real life experience.
Their Criteria for mastectomy and creation of a male chest in female to male (FtM) patients are:
1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country, (earlier preferably after ample time of living in the desired gender role and after one year of testosterone treatment).;
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.
In this case their criteria have been met because he has lived as a male and been on hormone therapy for over a year, there are no other significant medical or mental health concerns, and the gender dysphoria is well documented and persistent.

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


Answer: The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for "chest pain likely as a consequence of cough secondary to irritation from lung cancer" with a plan for serial troponin measurement and pain control.

Answer: Following admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist.

Context:
The patient is a female with metastatic lung cancer who presented to the Emergency Department with a primary complaint of chest pain, with associated cough and vomiting. She is currently receiving chemotherapy and has a history of mycobacterium avium-intracellulare (MAI) infection as well. Workup in the emergency room (ER) showed abnormal chest imaging as well as new electrocardiogram (EKG) changes. Vital signs and physical examination were non-diagnostic. She was admitted for "chest pain likely as a consequence of cough secondary to irritation from lung cancer" with a plan for serial troponin measurement and pain control.
Following admission, her troponins were negative. Oncology and Interventional Radiology were consulted, and she underwent a therapeutic thoracentesis. On the day after admission, she was discharged home with a plan for follow-up with her oncologist.

The health plan's determination of medical necessity is upheld.

No, the requested health service of inpatient stay was not medically necessary.
This admission does not meet criteria for inpatient acute medical admission based upon the standard Milliman Care Guidelines (MCG) guidelines for chest pain, which was both the chief complaint in the ER and the principal diagnosis by the admitting and discharging doctor. The hospital argued that there was concern the signs and symptoms may develop into a serious medical condition. Unfortunately, that is not backed up in any way by the medical documentation from the doctors involved in her care.
In fact, the actual documented assessment and plan of her condition was lacking and does not demonstrate that concern. In fact, it suggests that his belief was that her lung cancer was the cause of her chest pain (but there was no plan to address that). There was no explanation for the EKG abnormalities or how it potentially could represent something serious like acute coronary syndrome, nor does it have a treatment strategy for a serious condition. There were no high risk features of life-threatening acute disease, such as significantly abnormal vital signs or elevated troponin, and pretest probability for a condition requiring cardiac intervention was low (Penumetsa 2012). Her HEART score was only 2, which suggests a very low risk of major cardiac events (Backus 2013). Without supportive documentation, an inpatient stay was not medically necessary, and could have been managed at a lower level of care status, which is appropriate for most chest pain patients even if there is adequate documentation of concerning features.

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


Answer: This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.

Answer: The patient

Answer: had a history of lower back pain and neuropathy.  He was tobacco dependent.

Context:
This is a patient who presented with a request for detoxification services.  The patient reported that he was using alcohol on a continuous daily basis together with the use of crack cocaine and Xanax.  He has a history of bipolar mood disorder and posttraumatic stress disorder with associated symptoms of anxiety.  He was taking Seroquel and Lexapro to address the mood, trauma and anxiety disorders.  He had received multiple past substance use disorder treatments including three recent detoxification treatment episodes.  He had also received multiple other detoxification treatments in the year prior to his presentation without significant follow up for aftercare or use of medication assisted treatment.
The patient provided no history of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal symptoms.  He had no acute general medical problems; he had a history of lower back pain and neuropathy.  He was tobacco dependent.
The health plan's determination is upheld.
The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring.  The patient displayed no serious disturbance of mental status, despite having a history of ongoing substance use disorder with alcohol and use of crack cocaine and Xanax.  Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment.  There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently.

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


Answer: The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid

Answer: Patient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1.

Context:
The patient presented to the emergency department (ED) just before midnight with the complaint of coughing and breathing fast for two days. The patient has a history of asthma and did not improve following albuterol. The patient also also began vomiting. The Vital Signs on ED arrival were a temperature of 99.0F, heart rate (HR) 142, respiratory rate (RR) 48, blood pressure (BP) 114/76, and pulse oximetry 90%. The patient was started on supplemental oxygen and given nebulizer treatments and oral steroid
Patient was admitted with a diagnosis of status asthmaticus. After admission placed on albuterol every 2 hours, oxygen, and continued on PO steroid. Patient was also suspected to have a left lower lobe pneumonia and was started on intravenous (IV) ampicillin for this. Patient had initially a poor clinical response to treatment and was then given IV magnesium sulfate x1. The health plan determination is overturned in whole. The inpatient stay was medically necessary. This patient had respiratory distress as indicted by tachypnea and significant retractions and decreased oxygen saturations. Patient had vomiting secondary to increased work of breathing. The severity of his symptoms and poor response to initial treatment warranted inpatient medical care.

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


Answer: Diagnosis: Ascending lymphangitis

Answer: Treatment: Inpatient admission

Answer: The insurer denied coverage for inpatient admission.

Answer: This patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.

Answer: In the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm.

Answer: This was

Answer: ascending lymphangitis. There was no lymphadenopathy.

Answer: She was admitted for IV antibiotics and observation

Answer: these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally

Context:
Diagnosis: Ascending lymphangitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female child with a history of intermittent asthma and allergy to peanut butter who presented to the Emergency Department (ED) with the chief complaint of left arm redness and pruritus. The parent clearly gave the history of this beginning as a small white dot on the dorsum of her finger (2nd metacarpophalangeal joint), which she thought was a bug bite, and reported that by the next morning she woke up with erythema and local itchiness. There was no pain or fever by history.

In the ED she had no fever and her vital signs were stable. On examination there was a tiny scab on the dorsal aspect of the left hand with surrounding erythema, and erythema and swelling tracking up the left forearm, but this was not tender to palpation. There were additional areas of redness and warmth on ventral aspect of the wrist with streaking up the forearm and another area of warmth and redness proximal to the elbow on the upper arm. There was no sign of fluctuance, abscess or drainage. This was a classic presentation of ascending lymphangitis. There was no lymphadenopathy.
The documentation shows that it was unlikely that the cause was infectious, that she had no signs of sepsis, and that she had normal laboratory values. She was admitted for IV antibiotics and observation, but the rationale for that is not documented. Although these areas of redness representing lymphangitis were extensive, the largest being 16.5 cm measured longitudinally, there was no evidence of deeper soft tissue involvement, (no evidence of tenosynovitis, joint involvement, muscle involvement, fasciitis, or compartment syndrome). The patient had no complaints of pain; she had itching and discomfort. Given her age, after receiving 1 dose of IV Clindamycin, the patient could safely have been treated and observed as an outpatient on oral antibiotics to cover both group A Strep and Staphylococcus aureus infection as possible bacterial causes of her cellulitis with lymphangitis secondary to the dorsum of hand lesion as the portal of entry.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.

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


Answer:
Diagnosis: Testicular cancer
Issue under review: PET/CT

Answer: The AP's note that, "... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity,"

Context:
Diagnosis: Testicular cancer
Issue under review: PET/CT

Determination:
The PET/CT is not medically necessary.

For a residual mass under 3cm for pure seminoma with normal tumor markers, the NCCN does not recognize the role of PET/CT for disease management.  Per the NCCN, a patient such as this should be placed on surveillance, and there would be no role for PET/CT, as the patient's lymph node disease is all under 3cm.

The AP's note that, "... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity," is not correct. Per the NCCN, PET/CT should only be performed if a residual mass is over 3cm. Per the NCCN, following completion of chemotherapy CT scans should be performed, and then, if a mass is over 3cm, then PET/CT can be performed. The NCCN does not base the use of PET/CT on the size of the original masses. This patient's residual LN was less than 3cm, and therefore would not support a PET/CT. Therefore, the 78815 - PET CT is not medically necessary.

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


Answer: The patient is a male who presented to the emergency department requesting detoxification/rehabilitation and was medically screened and admitted to inpatient level services for detoxification of opioids, cocaine, Xanax and alcohol use; he had been using up to 14 bags of heroin with intravenous (IV) administration together with up to one gram of cocaine, as well as use of 4 milligrams (mg) of Xanax and alcohol. His substance use disorder had its onset in adolescence with progression of the disease over a ten year time frame with severe opioid, stimulant sedative-hypnotic-anxiolytic and alcohol class substance use disorders. The patient reported a past history of withdrawal seizures two years prior to admission but had no history of delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with

Answer: complaints of loose stool, headache and chills.

Answer: The patient was admitted and placed on a detoxification regimen with comfort medications, as well as vitamin replacement therapy. He was prescribed quetiapine, sertraline and gabapentin to address his mental health conditions.

Answer: The patient received counseling and education from the staff.

Answer: the patient was discharged with referral for

Answer: aftercare and rehabilitation services.

Answer: The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis.

Context:
The patient is a male who presented to the emergency department requesting detoxification/rehabilitation and was medically screened and admitted to inpatient level services for detoxification of opioids, cocaine, Xanax and alcohol use; he had been using up to 14 bags of heroin with intravenous (IV) administration together with up to one gram of cocaine, as well as use of 4 milligrams (mg) of Xanax and alcohol. His substance use disorder had its onset in adolescence with progression of the disease over a ten year time frame with severe opioid, stimulant sedative-hypnotic-anxiolytic and alcohol class substance use disorders. The patient reported a past history of withdrawal seizures two years prior to admission but had no history of delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 2 and Clinical Opiate Withdrawal Scale (COWS) scale score of 6 reflecting minimal withdrawal symptoms and complaints of loose stool, headache and chills.

The patient was admitted and placed on a detoxification regimen with comfort medications, as well as vitamin replacement therapy. He was prescribed quetiapine, sertraline and gabapentin to address his mental health conditions. The detoxification was uncomplicated with regard to withdrawal management. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and the patient was discharged with referral for clinically appropriate aftercare and rehabilitation services.

The health plan's determination is upheld.

The requested inpatient substance abuse treatment and withdrawal management could have been safely and effectively provided at a lower level of care status. The patient in this case was using heroin, alcohol, cocaine and other substances of abuse on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe and the patient had received detoxification treatment 7-8 days prior to his presentation accounting for minimal or light withdrawal symptoms, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of recent complicated withdrawal from drugs or alcohol despite the history of withdrawal seizures two years prior to presentation. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested benefit of an admission and continued inpatient detoxification and other medical services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria, scientific literature, referenced below. Additionally, medical necessity for the requested inpatient detoxification and other medical services is not met in keeping with NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.

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


Answer:
Diagnosis: Right upper quadrant pain, hepatocellular carcinoma
Treatment: Inpatient admission

Answer: In the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well

Answer: He

Answer: remained hemodynamic stable

Answer: He was

Answer: seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention.

Context:
Diagnosis: Right upper quadrant pain, hepatocellular carcinoma
Treatment: Inpatient admission

Summary:
In the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well and did not have any episode of vomiting. He also remained hemodynamic stable, and did not have episode of hemodynamic instability, no evidence of any infection. He was also seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention. Given this clinical scenario, the patient could have been appropriately managed at the lower level of care, and acute level care was not appropriate and medically necessary.

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


Answer:
Diagnosis: Alcohol use disorder; psychosis
Treatment: Inpatient Hospital Admission

Answer: The patient exhibited cognitive impairment (disorder thought processing and executive function) and perceptual disturbance (presence of perceptual disturbance- hallucinations) acting on his paranoid thought content with guarded behavior and medication non-adherence and substance abuse with alcohol, and a decline in functioning with limited insight.

Context:
Diagnosis: Alcohol use disorder; psychosis
Treatment: Inpatient Hospital Admission
The proposed treatment, continued Inpatient hospital admission, was not medically necessary for this patient.

The continued inpatient level hospital care was not medically necessary for this patient. The patient no longer required the structure of an acute inpatient level of care in order to remain safe or to administer continued treatment for the psychiatric disturbance including support of daily activities and safety monitoring together with medication management and other therapeutic interventions. It was not medically necessary for this patient to receive continued acute inpatient level services in view of his improved mood and affect, resolution of overtly psychotic symptoms, and relative lack of impulsive behaviors, as well as improved insight and cooperation with staff with regard to daily functioning and medication adherence. There were no general medical issues or co-occurring substance use disorders complicating this case that would have required continued acute inpatient level services; the patient's alcohol use disorder did not require continued acute inpatient level treatment or 24-hour monitoring. Additionally, the inpatient stay during the time interval under review was not medically necessary in order to monitor the patient for at-risk behaviors, or to address the acute risk of relapse or address the issue in this case with medication non-adherence. The patient had access to continued mental health and substance abuse treatment in the community that could effectively meet the patient's continued mental health needs. Thus, treatment could have continued in a less restrictive setting and medical necessity is not met in this case for the time interval under review. This answer is consistent with the practice guidelines and scientific literature referenced below as well as New York State instruction for medical necessity reviews.

The patient's presentation and clinical features included an exacerbation of the patient's psychotic and mood disorder in the context of severe symptoms of psychosis, depression, and deterioration in functioning. The patient exhibited cognitive impairment (disorder thought processing and executive function) and perceptual disturbance (presence of perceptual disturbance- hallucinations) acting on his paranoid thought content with guarded behavior and medication non-adherence and substance abuse with alcohol, and a decline in functioning with limited insight. The patient responded to treatment such that by the dates in question, he had no remaining safety issues or persistent symptoms of psychosis that placed him at imminent risk for harm to self or others. There was no evidence of other symptoms or behaviors that would have required continued acute inpatient level of care, as noted above. The patient could have been managed at a lower level of care during the time frame under review. Thus, the health plan's determination is reasonable and reflects sound medical judgment. This answer is consistent with the practice guideline and scientific literature referenced below as well as New York State instruction for medical necessity reviews, and other references pertinent to the patient's co-occurring alcohol use disorder and severe and persistent mental disorder.

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


Answer: Diagnosis: Right-sided flank pain and groin pain

Answer: Treatment: Inpatient hospital services

Answer: The insurer denied the Inpatient hospital services.

Answer: This patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.

Answer: The plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged.

Context:
Diagnosis: Right-sided flank pain and groin pain

Treatment: Inpatient hospital services

The insurer denied the Inpatient hospital services. The denial was reversed.

This patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.

The plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged.

According to referenced literature, an inpatient admission may be needed for a patient when there is evidence of kidney stones as well as severe pain, urinary tract infection, the need for IV hydration, and a stone removal procedure is needed.  Within the documentation it was noted this patient did present complaining of worsening flank pain.  The documentation did detail she had recently been seen and diagnosed with a kidney stone.  She was recommended to have a stent placed however did not do so.  Therefore, the inpatient admission was needed as she did have prior care with ongoing worsening symptoms.  The documentation did detail she required morphine for pain control and had evidence of large blood in her urine.  The patient needed IV hydration as well and a stone removal procedure.  The patient underwent surgical intervention and continued to have rose-colored blood drain into her Foley.  She also complained of nausea and vomiting postoperatively.  Therefore, the continued inpatient services were the most appropriate level of care that could have been provided to this patient.  The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.

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


Answer: This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence.

Context:
This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence.

The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma.  However, the test is not the standard of care.  The DecisionDx-Melanoma test is not recommended by the panel of expert authors of UpToDate. The following are the guidelines for diagnosis and prognosis of cutaneous melanoma offered by the expert authors in UpToDate: "SUMMARY - A simple, accurate staging and prognostic system provides important insight into the prognosis of patients with cutaneous melanoma, thus facilitating appropriate treatment.  Staging and prognosis are based upon the tumor (T) node (N) metastasis (M) system, which incorporates information about the primary tumor, regional lymphatics, and potential distant metastatic sites."

The patient would not be considered a good candidate for the requested testing and it was not the best available treatment for the patient at the time of testing.  As such, the requested service is not likely to be more beneficial than any other standard treatment or procedure.

The carrier's denial of coverage for DecisionDX-Melanoma testing should be upheld.

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


Answer: This is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.

Answer: Diagnosis: Hematemesis

Answer: Treatment: Inpatient Hospitalization

Answer: The insurer denied the Inpatient Hospitalization.

Context:
Diagnosis: Hematemesis

Treatment: Inpatient Hospitalization

The insurer denied the Inpatient Hospitalization. The denial was upheld.

This is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.

Per MCG, clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy that is moderate to severe and unresponsive to observation treatment, infected ascites, severe hepatitis, severe vomiting, and acute hepatic decompensation. The patient did not have these conditions. Gastrointestinal (GI) bleeding is an indication for admission. However, in this case, there was no evidence of active GI bleeding either by history or based on the endoscopic findings. The patient did not have any high risk endoscopic features and was hemodynamically stable. The patient only reported a minimal amount of blood after he vomited. This patient had cirrhosis. There was no indication of an active GI bleed.

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated.  The insurer's denial is upheld.

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


Answer: The patient is a male who presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient has participated in a medication assisted treatment (MAT) program with Suboxone which he was only taking sporadically; he indicated that he wanted to come off of Suboxone, as well as receiving detoxification treatment for his use of heroin with up to 6 bags used daily with intranasal administration (snorting). He had ten years of sobriety following ten years of incarceration in prison but had relapsed twice in 2018 and again in 2019 despite being on probation and participating in outpatient treatment with Medicated-Assisted Treatment (MAT).

Answer: The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a three day Suboxone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. The patient had persistent and mild symptoms of withdrawal scoring an 8 on the COWS scale on hospital days two, three and four, but the patient tolerated the taper of Suboxone. The day following his last dose of Suboxone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. While in detoxification treatment the patient continued to receive counseling and education and attended groups.

Answer: The patient completed the detoxification protocol and was discharged with referral for rehabilitation substance use disorder treatment, and with recommendations for smoking cessation, as well as recommended involvement with recovery groups and follow-up for clinically appropriate treatment of his co-occurring depressive disorder and primary care.

Context:
The patient is a male who presented for inpatient detoxification treatment in order to address severe substance use disorder with opioid (heroin) class substance of abuse. The patient has participated in a medication assisted treatment (MAT) program with Suboxone which he was only taking sporadically; he indicated that he wanted to come off of Suboxone, as well as receiving detoxification treatment for his use of heroin with up to 6 bags used daily with intranasal administration (snorting). He had ten years of sobriety following ten years of incarceration in prison but had relapsed twice in 2018 and again in 2019 despite being on probation and participating in outpatient treatment with Medicated-Assisted Treatment (MAT).

The patient was admitted to detoxification treatment with a comprehensive detoxification protocol with a three day Suboxone taper, and as needed (prn) medications for comfort including medication to address pain and aches, anxiety and insomnia and diarrhea/abdominal cramps. The patient had persistent and mild symptoms of withdrawal scoring an 8 on the COWS scale on hospital days two, three and four, but the patient tolerated the taper of Suboxone. The day following his last dose of Suboxone, the patient was immediately referred to rehabilitation treatment which had followed the use of motivational techniques by the treatment team and case manager. While in detoxification treatment the patient continued to receive counseling and education and attended groups.
The patient completed the detoxification protocol and was discharged with referral for rehabilitation substance use disorder treatment, and with recommendations for smoking cessation, as well as recommended involvement with recovery groups and follow-up for clinically appropriate treatment of his co-occurring depressive disorder and primary care.

The health plan's determination is overturned.

The continued inpatient treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment and risk factors for relapse and lack of a reasonable treatment/recovery environment. Withdrawal symptoms were appropriately managed with tapering dosages of Suboxone requiring monitoring and supportive measures including the availability of comfort medications, as noted in the clinical summary. The patient's history of opioid use and recent relapses while receiving MAT, limited psychosocial supports and psychosocial stressors within several domains including risk for re-incarceration, and risk for relapse in view of his recent relapses did reflect the seriousness of the substance use disorder and a complicated case with regard to the ongoing struggle with addiction to opioids.

Thus, the patient did require a safe and effective detoxification treatment with continued inpatient services as it was foreseeable that the patient was unable to abstain from use of heroin, or maintain abstinence if detoxification were to be attempted at a lower level of care. Moreover, using the of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, the patient did warrant the continued inpatient level care through discharge with the clinically appropriate application of the LOCADTR Guidelines.

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


Answer: This is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up.

Answer: Diagnosis:  Deep Vein Thrombosis

Answer: Treatment:  Inpatient Admission

Answer: The insurer denied the Inpatient Admission.

Context:
Diagnosis:  Deep Vein Thrombosis

Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.

This is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up.

According to current literature a patient may be admitted to inpatient care when there is evidence the patient is considered a high risk for acute complication, such as documentation of a recent surgery, recent Gastrointestinal (GI) bleed, and history of intracranial bleeding, history of active bleeding with anti-coagulation or there is evidence of active substance abuse.  Additionally, if there is a limb threatening infection, then a patient may be admitted.  The submitted documentation did not indicate any of the above conditions.  There is no personal allergic reaction in response to anticoagulation requiring monitoring beyond observation care that would warrant the requested inpatient stay.  There is a lack of submitted documentation detailing why this patient could not have continued care in an observation level.  The patient could have been observed and treated with anticoagulation therapy.  Therefore, the inpatient admission was not medically necessary, and the prior denial remains upheld.  The health plan acted reasonably and 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.

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


Answer: The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity.

Context:
The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity. The subject under review is the medical necessity for the requested orthodontic treatment.

The health plan's determination is upheld.

The requested treatment is not medically necessary for this patient.
The patient has an excellent occlusion and appropriate overbite and overjet. There is some minor spacing, but this alone does not rise to the threshold of medically necessary. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. Although the patient has some minor spacing, his teeth are in a solid Class I occlusal relationship. He has minimal overbite and overjet on 7 and 10, but the photographs do not indicate any incisors in a traumatic relationship. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.

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


Answer:
Diagnosis: Pain due to Sickle Cell
Treatment: Inpatient admission

Answer: The patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough.

Answer: The patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands.

Answer: The patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation.

Answer: The patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days.

Context:
Diagnosis: Pain due to Sickle Cell
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough.

The patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands.

The patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation.

The patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days.

This male teen presented with abdominal pain characteristic of previous vasoocclusive crises, preceded by extremity pain, rated 6/10. He had failed outpatient treatment with Percocet, and required Dilaudid in the ED with marginal improvement. He had a cough but was otherwise stable with no fevers. He was due for his routine transfusion. Based on his presentation and the standard of care at the time, acute inpatient admission for parenteral pain management was medically necessary and appropriate. This intensity of care could not have been safely provided at a lower level.

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


Answer:
Diagnosis: Fever, vomiting
Issue under review: Inpatient admission

Answer: This patient presented to the ED with signs and symptoms consistent with viral infection. Because of persistent tachycardia despite fluid resuscitation and antipyretics, additional studies were obtained that were indicative of myocarditis. She was initially admitted to the PICU for cardiorespiratory monitoring. She remained stable overnight, so was able to transfer to the pediatric floor. Once her symptoms resolved (afebrile, able to tolerate a regular diet, decreased fatigue) she was considered at decreased risk for complications and stable to go home.

Answer: Additionally, she was treated with broad-spectrum antibiotics pending culture results.

Context:
Diagnosis: Fever, vomiting
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

Myocarditis is an inflammatory disease of heart muscle. There are numerous causes, including infection, autoimmune disease, hypersensitivity reactions, and toxins. In developed countries, the cause is usually viral. Enteroviruses are the classic viral pathogen, but other viral agents may cause myocarditis, including adenovirus, parvovirus, Epstein-Barr virus, and cytomegalovirus. Characteristic symptoms on presentation include tachypnea, abdominal pain, vomiting, chest pain, palpitations, and tachycardia.

Most patients present with resting tachycardia. Electocardiographic findings include ST-T wave abnormalities and premature contractions. Inflammatory markers are typically elevated. Troponin is a particularly useful marker to trend the disease. The most common echocardiographic finding is dilated cardiomyopathy with left ventricular dilation and reduced ejection fraction, but other phenotypes may be present. Cardiac MRI is particularly useful, because it can be used to assess left ventricular ejection, chamber size, wall thickness, and local areas of edema and fibrosis. Specific MRI diagnostic criteria are available for suspected myocarditis.

Complications of myocarditis include arrhythmias, chest pain, myocardial infarction, acute heart failure, and sudden death. Treatment includes limitation of aerobic activities and management of the primary medical manifestations (e.g., treatment of arrhythmias, heart block, decreased left ventricular function). Research has suggested a role for immunosuppressive therapies and antiviral therapies.

This patient presented to the ED with signs and symptoms consistent with viral infection. Because of persistent tachycardia despite fluid resuscitation and antipyretics, additional studies were obtained that were indicative of myocarditis. She was initially admitted to the PICU for cardiorespiratory monitoring. She remained stable overnight, so was able to transfer to the pediatric floor. Once her symptoms resolved (afebrile, able to tolerate a regular diet, decreased fatigue) she was considered at decreased risk for complications and stable to go home. Myocarditis is a serious disease, with potential for significant morbidity and even mortality. Appropriate medical management in this situation included ICU monitoring, Cardiology and ID (infectious diseases) consultations, and comprehensive diagnostic studies. Additionally, she was treated with broad-spectrum antibiotics pending culture results. Acute inpatient management was medically necessary and appropriate. She could not have been safely managed at a lower level of care.

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


Answer: Diagnosis: Urinary Tract Infection

Answer: Treatment: Inpatient Admission

Answer: The insurer denied the Inpatient Admission.

Answer: This is a female patient who presented to the Emergency Department with complaints of fever, chills, and dysuria. She has a past medical history of diabetes mellitus, hyperlipidemia, and parotid gland drainage. The patient was empirically started on intravenous antibiotics for treatment of her urinary tract infection (UTI). The chest x-ray was negative. A renal ultrasound was negative for hydronephrosis. The urine culture was positive for E. coli.  The patient remained hemodynamically stable and clinically improved. She was discharged to continue antibiotics as an outpatient management.

Answer: According to the medical records, the patient was treated by her primary physician for a UTI as an outpatient with antibiotics for three days without improvement. She presented with high fevers (39.3 C) and tachycardia (heart rate-132). Urinalysis and cultures confirmed an E. coli UTI. The patient had multiple co-morbid conditions including diabetes that placed her at high-risk for complications.

Context:
Diagnosis: Urinary Tract Infection

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.

This is a female patient who presented to the Emergency Department with complaints of fever, chills, and dysuria. She has a past medical history of diabetes mellitus, hyperlipidemia, and parotid gland drainage. The patient was empirically started on intravenous antibiotics for treatment of her urinary tract infection (UTI). The chest x-ray was negative. A renal ultrasound was negative for hydronephrosis. The urine culture was positive for E. coli.  The patient remained hemodynamically stable and clinically improved. She was discharged to continue antibiotics as an outpatient management.

According to the medical records, the patient was treated by her primary physician for a UTI as an outpatient with antibiotics for three days without improvement. She presented with high fevers (39.3 C) and tachycardia (heart rate-132). Urinalysis and cultures confirmed an E. coli UTI. The patient had multiple co-morbid conditions including diabetes that placed her at high-risk for complications.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated. The insurer's denial is reversed.

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


Answer: This is a female patient who presented to the hospital for scheduled percutaneous coronary intervention (PCI) of left anterior descending artery. She has a history of hypertension, hyperlipidemia, two vessel coronary artery disease (CAD) (right coronary artery, and left anterior descending artery), status post DES of right coronary artery. Immediately post procedure she experienced nausea and chest pain. She was given nitroglycerin and Zofran. She was treated with antiplatelet therapy and remained clinically and hemodynamically stable throughout her hospital stay. She was discharged home for outpatient follow up.

Answer: Diagnosis: Coronary artery disease (CAD)

Answer: Treatment: Inpatient Admission

Answer: The insurer denied the Inpatient Admission.

Context:
Diagnosis: Coronary artery disease (CAD)

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.

This is a female patient who presented to the hospital for scheduled percutaneous coronary intervention (PCI) of left anterior descending artery. She has a history of hypertension, hyperlipidemia, two vessel coronary artery disease (CAD) (right coronary artery, and left anterior descending artery), status post DES of right coronary artery. Immediately post procedure she experienced nausea and chest pain. She was given nitroglycerin and Zofran. She was treated with antiplatelet therapy and remained clinically and hemodynamically stable throughout her hospital stay. She was discharged home for outpatient follow up.

Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization, angioplasty, and coronary stenting.

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated. The insurer's denial is upheld.

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


Answer: The patient is a female with a history of a ruptured ovarian cyst, syncope and chronic back pain. She presented to the emergency room with abdominal pain, diarrhea, vomiting, and palpitations. Her vital signs were unremarkable, she appeared well and in no acute distress. There was slight epigastric tenderness. Except for a minimally elevated troponin, the labs, chest x-ray, and the electrocardiogram (EKG) were essentially normal.

Answer: due to the complaint of palpitations and the minimally elevated troponin, the patient was admitted.

Answer: Upon admission, she was placed in a telemetry bed. An echocardiogram was normal. The hospital course was clinically uneventful, and the patient was discharged the following day.

Context:
The patient is a female with a history of a ruptured ovarian cyst, syncope and chronic back pain. She presented to the emergency room with abdominal pain, diarrhea, vomiting, and palpitations. Her vital signs were unremarkable, she appeared well and in no acute distress. There was slight epigastric tenderness. Except for a minimally elevated troponin, the labs, chest x-ray, and the electrocardiogram (EKG) were essentially normal. Apparently, due to the complaint of palpitations and the minimally elevated troponin, the patient was admitted.

Upon admission, she was placed in a telemetry bed. An echocardiogram was normal. The hospital course was clinically uneventful, and the patient was discharged the following day.
The health plan's determination is upheld.

No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. The services provided could have been safely and efficiently provided at a lesser level. The probability of an acute coronary syndrome was extremely low.

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


Answer: This is a patient is a patient with a past medical history significant for alcohol abuse, polysubstance abuse, depression, gastroesophageal reflux disease (GERD), and suicidal ideation who presented to the emergency department with alcohol intoxication and withdrawal symptoms.

Answer: The patient was admitted to the hospital and received treatment for alcohol withdrawal symptoms based on the Clinical Institute Withdrawal Assessment (CIWA) protocol. She also received treatment with intravenous fluids, thiamine, multivitamins, folic acid. It was indicated in the discharge summaries that the patient had signs of severe withdrawal.

Answer: Subsequently, patient's alcohol withdrawal symptoms completely resolved, and she was discharged home with a recommendation to follow up with a primary care physician as well as to attend alcohol anonymous group.

Context:
This is a patient is a patient with a past medical history significant for alcohol abuse, polysubstance abuse, depression, gastroesophageal reflux disease (GERD), and suicidal ideation who presented to the emergency department with alcohol intoxication and withdrawal symptoms.
The patient was admitted to the hospital and received treatment for alcohol withdrawal symptoms based on the Clinical Institute Withdrawal Assessment (CIWA) protocol. She also received treatment with intravenous fluids, thiamine, multivitamins, folic acid. It was indicated in the discharge summaries that the patient had signs of severe withdrawal.
Subsequently, patient's alcohol withdrawal symptoms completely resolved, and she was discharged home with a recommendation to follow up with a primary care physician as well as to attend alcohol anonymous group. The health plan's determination is overturned.
This patient was admitted to the hospital with alcohol withdrawal symptoms. Even though in some cases a patient with mild alcohol withdrawal symptoms could be managed as an outpatient and at the lower level of care, patients with moderate to severe withdrawal symptoms require admission to the hospital. They need very close monitoring, assessment of the withdrawal symptoms based on the CIWA score, and proper administration of benzodiazepines in accordance with CIWA protocol. In this particular case, the patient had a relatively low CIWA score, with several spikes in the CIWA score up to 26, which was in a category of severe withdrawal. Therefore, this patient had episodes of severe alcohol withdrawal qualifying for inpatient level of care.

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