Answer: Diagnosis: Respiratory System. Treatment: Inpatient Hospital. The insurer denied Inpatient Stay.

Answer: The patient is a girl with a past medical history significant for seasonal allergies who presented to the emergency department for evaluation of a sore throat. It was reported that the patient started to have a fever and sore throat. She presented to the emergency department, and at that time was noted to have right tonsillar hypertrophy and uvular deviation. Rapid Streptococcus test was positive. The ear, nose, and throat (ENT) service was consulted, and the patient was diagnosed with tonsillitis. The patient was discharged from the hospital with Augmentin. The patient's mother stated that she checked her tonsils regularly and was under the impression that the swelling became worse. The patient's mother stated that the patient had minimal relief of the throat pain despite using Tylenol, Motrin, and saltwater gargles. Because of the pain, the patient was unable to eat and only drank fluids. The patient was still able to swallow her secretions and had normal urinary output. The patient's mother denied difficulties breathing while awake. The patient's mother denied lethargy, syncope, seizure, cough, congestion, rhinorrhea, wheezing, vomiting, diarrhea, swelling in the extremities, or skin rash.

Answer: At the time of the initial evaluation, the patient's temperature was 98.6 F, blood pressure was 106/74, pulse rate was 139 beats per minute (bpm), respiratory rate was 20 breaths/minute, and oxygen saturation was 100% on room air.

Answer: The patient was sitting in an upright position in a chair, playing on a tablet. She looked nontoxic. On the head, eyes, ears, neck, throat (HEENT) exam, there was significant right tonsillar hypertrophy with exudate and uvular deviation to the right. There was tonsillar and right anterior cervical lymphadenopathy. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The rest of the exam was unremarkable. The patient was admitted to the hospital with tonsillar swelling.

Answer:
The patient was admitted to the hospital with a diagnosis of bacterial tonsillopharyngitis and a marked decrease in oral intake. In the hospital, the patient was managed with intravenous Unasyn, intravenous fluids, Tylenol, and Motrin. Within the first 24 hours of admission, her oral intake considerably improved, and she remained afebrile.
At issue is the medical necessity of Inpatient Stay.

Answer: The patient presented to the hospital with tonsillopharyngitis.

Answer: At the time of the presentation, the patient was afebrile, and had a normal blood pressure. She was initially tachycardic, but the tachycardia improved within a short period of time. At the time of the initial evaluation, the patient was not in any distress. She had a normal respiratory rate and normal oxygen saturation.

Answer: During the hospitalization, the patient remained afebrile and hemodynamically stable

Answer: she was discharged home on the second day after the day of admission.

Context:
Diagnosis: Respiratory System. Treatment: Inpatient Hospital. The insurer denied Inpatient Stay. The denial is upheld.

The patient is a girl with a past medical history significant for seasonal allergies who presented to the emergency department for evaluation of a sore throat. It was reported that the patient started to have a fever and sore throat. She presented to the emergency department, and at that time was noted to have right tonsillar hypertrophy and uvular deviation. Rapid Streptococcus test was positive. The ear, nose, and throat (ENT) service was consulted, and the patient was diagnosed with tonsillitis. The patient was discharged from the hospital with Augmentin. The patient's mother stated that she checked her tonsils regularly and was under the impression that the swelling became worse. The patient's mother stated that the patient had minimal relief of the throat pain despite using Tylenol, Motrin, and saltwater gargles. Because of the pain, the patient was unable to eat and only drank fluids. The patient was still able to swallow her secretions and had normal urinary output. The patient's mother denied difficulties breathing while awake. The patient's mother denied lethargy, syncope, seizure, cough, congestion, rhinorrhea, wheezing, vomiting, diarrhea, swelling in the extremities, or skin rash.

At the time of the initial evaluation, the patient's temperature was 98.6 F, blood pressure was 106/74, pulse rate was 139 beats per minute (bpm), respiratory rate was 20 breaths/minute, and oxygen saturation was 100% on room air.

The patient was sitting in an upright position in a chair, playing on a tablet. She looked nontoxic. On the head, eyes, ears, neck, throat (HEENT) exam, there was significant right tonsillar hypertrophy with exudate and uvular deviation to the right. There was tonsillar and right anterior cervical lymphadenopathy. Her lungs were clear to auscultation without wheezes, rales, or rhonchi. The rest of the exam was unremarkable. The patient was admitted to the hospital with tonsillar swelling.
The patient was admitted to the hospital with a diagnosis of bacterial tonsillopharyngitis and a marked decrease in oral intake. In the hospital, the patient was managed with intravenous Unasyn, intravenous fluids, Tylenol, and Motrin. Within the first 24 hours of admission, her oral intake considerably improved, and she remained afebrile.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient presented to the hospital with tonsillopharyngitis. Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus). In about 30% of patients, the cause is bacterial. Group A beta-hemolytic streptococcus (GABHS) is most common. At the time of the presentation, the patient was afebrile, and had a normal blood pressure. She was initially tachycardic, but the tachycardia improved within a short period of time. At the time of the initial evaluation, the patient was not in any distress. She had a normal respiratory rate and normal oxygen saturation. There was no strider or wheezing reported. It was indicated in the notes that the patient's oral intake considerably improved within the first 24 hours of hospitalization. During the hospitalization, the patient remained afebrile and hemodynamically stable, to the point that she was discharged home on the second day after the day of admission.
Overall, this young patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Stay is not medically necessary for this patient.

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


Answer: The patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.

Answer: Diagnosis: Dental Problems/Other/ Class I Occlusion

Answer: Treatment: Dental/Orthodontic Procedure

Answer: The health plan denied the requested dental treatment plan.

Context:
Diagnosis: Dental Problems/Other/ Class I Occlusion
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested dental treatment plan.
The health plan's determination is upheld.

The patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and monthly visits are not medically necessary for this case.

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


Answer: This female presented to the ED with a various constellation of complaints, most prominently lower extremity weakness with a history of recent viral infection. There was initial concern about Guillain-Barre syndrome so she was admitted for monitoring. She was evaluated by a number of subspecialists during her hospitals stay, with no definitive answer found for her lower extremity weakness.

Answer: Diagnosis: Leg weakness

Answer: Treatment: Inpatient Hospital Stay

Answer: The insurer denied the Inpatient Hospital Stay.

Answer: The patient has a history significant for attention deficit hyperactivity disorder (ADHD) inattentive type, tic disorder, recent coronavirus 2019 (COVID 19) infection the month prior, and acute gastroenteritis a month prior, who presented to the ED with excessive clumsiness and bilateral leg weakness. She had fallen multiple times over the previous couple of days, and on the day of presentation experienced some dizziness and had a brief loss of consciousness but no loss of bowel or bladder control. In the ED, the evaluation was unremarkable, including a negative head computed tomography (CT) scan. On the pediatric floor, the vital signs included a temperature of 36.9 degrees Celsius, heart rate 96, respiratory rate 20, and blood pressure 98/72. The examination was significant for mild bilateral nystagmus, hypoactive reflexes, decreased power, bilateral extremity weakness. Laboratory evaluation was relatively unremarkable. Magnetic resonance imaging (MRI) of the spine was unremarkable, no significant abnormality.

Answer: Admission orders included continuous telemetry, possible lumbar puncture, neurology consultation, regular diet, continuous cardiac monitoring, and possibly cardiology consultation. During her hospitalization, she recovered her strength and balance. She was evaluated by psychiatry (no acute inpatient needs), neurology (recommended outpatient electromyography (EMG) / nerve conduction velocity (NCV)), and cardiology (follow-up electrocardiogram (EKG) and benign murmur in the outpatient setting. She was ambulating independently, neurologic exam within normal limits, and was deemed stable for discharge.

Answer: At issue is the medical necessity of an inpatient stay.

Context:
Diagnosis: Leg weakness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history significant for attention deficit hyperactivity disorder (ADHD) inattentive type, tic disorder, recent coronavirus 2019 (COVID 19) infection the month prior, and acute gastroenteritis a month prior, who presented to the ED with excessive clumsiness and bilateral leg weakness. She had fallen multiple times over the previous couple of days, and on the day of presentation experienced some dizziness and had a brief loss of consciousness but no loss of bowel or bladder control. In the ED, the evaluation was unremarkable, including a negative head computed tomography (CT) scan. On the pediatric floor, the vital signs included a temperature of 36.9 degrees Celsius, heart rate 96, respiratory rate 20, and blood pressure 98/72. The examination was significant for mild bilateral nystagmus, hypoactive reflexes, decreased power, bilateral extremity weakness. Laboratory evaluation was relatively unremarkable. Magnetic resonance imaging (MRI) of the spine was unremarkable, no significant abnormality.
Admission orders included continuous telemetry, possible lumbar puncture, neurology consultation, regular diet, continuous cardiac monitoring, and possibly cardiology consultation. During her hospitalization, she recovered her strength and balance. She was evaluated by psychiatry (no acute inpatient needs), neurology (recommended outpatient electromyography (EMG) / nerve conduction velocity (NCV)), and cardiology (follow-up electrocardiogram (EKG) and benign murmur in the outpatient setting. She was ambulating independently, neurologic exam within normal limits, and was deemed stable for discharge.
At issue is the medical necessity of an inpatient stay.
The requested inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care, including all consultations.
Guillain-Barre syndrome is an immune-mediated disease typically triggered by infectious diseases. The clinical presentation is variable making diagnosis sometimes challenging. Patients typically report an ascending weakness and sensory deficit, beginning in the legs and progressing up to the arms and cranial muscles. Diagnosis is based on history, neurological exam, cerebrospinal fluid (CSF) findings, and electrophysiologic data. Peak disability typically occurs in two weeks. About 20% go on to develop respiratory failure and require intubation with mechanical ventilation. Cardiac arrhythmias may occur if the autonomic nervous system is involved. Treatment may involve intravenous immunoglobulin (IVIG) or plasma exchange.
This female presented to the ED with a various constellation of complaints, most prominently lower extremity weakness with a history of recent viral infection. There was initial concern about Guillain-Barre syndrome so she was admitted for monitoring. She was evaluated by a number of subspecialists during her hospitals stay, with no definitive answer found for her lower extremity weakness. While it was not unreasonable to monitor her for progression or regression of symptoms, she was overall hemodynamically stable with no evidence of impending respiratory failure and no reported suicidal ideation. She did not require acute inpatient admission and could have been safely managed at a lower level of care.

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


Answer: The patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age.

Answer: Diagnosis: Atopic Dermatitis.

Answer: Treatment: Dupixent 300MG/2ML SOSY.

Answer: The insurer denied the Dupixent 300MG/2ML SOSY.

Context:
Diagnosis: Atopic Dermatitis.
Treatment: Dupixent 300MG/2ML SOSY.

The insurer denied the Dupixent 300MG/2ML SOSY.
The denial is upheld.

The patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age.

No, the requested Dupixent is not medically necessary.

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis.

According to the recommendations provided by Simpson et al, steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy.

Dupixent is not appropriate or medically necessary for this patient.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

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


Answer: This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services.

Answer: the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion.

Answer: Diagnosis: Trauma/Injuries/Spinal Cord Injury

Answer: Treatment: Skilled Nursing Facility/Custodial Care

Answer: The health plan denied the requested continued long term custodial care as not medically necessary.

Answer: The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy

Answer: At issue is the medical necessity for continued long-term custodial services.

Context:
Diagnosis: Trauma/Injuries/Spinal Cord Injury
Treatment: Skilled Nursing Facility/Custodial Care
The health plan denied the requested continued long term custodial care as not medically necessary.
The health plan's determination is upheld.

The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy.

At issue is the medical necessity for continued long-term custodial services.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.

The long-term custodial services would not be medically necessary, based on the clinical documentation reviewed. This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition was via an oral diet, he did not have an active complex comorbidity that needed treatment, and he was participating in physical therapy. All of the above requirements did not require frequent nursing care > (greater than) 6.5 hours per day, daily physician assessments, or by themselves requiring facility-based treatment. The patient can undergo custodial care at home with physical therapy services as an outpatient. Therefore, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.

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


Answer: This case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.

Answer: Diagnosis: Coronary Artery Disease

Answer: Treatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

Answer: The insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

Answer: This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke.

Context:
Diagnosis: Coronary Artery Disease

Treatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The denial is overturned.

This case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke.  Addition of a non-statin agent such Evolocumab in this setting has been associated with significant event rate reduction regardless of serum LDL level. (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (Proprotein convertase subtilisin/kexin type 9_ inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events including those with multivessel disease. (Reference 1,2,3).  Such patients are given a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C levels are greater than 55mg/dl. (Reference 3) In conclusion, the proposed treatment (evolocumab) is medically necessary.

The insurer's denial of coverage for the evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick) is overturned. Medical Necessity is substantiated.

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


Answer: Diagnosis: Parkinson's disease; osteoarthritis.

Answer: Treatment: Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).

Answer: The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).

Answer: The patient is a male. His medical conditions include Parkinson's disease, dementia, diabetes, osteoarthritis, and heart disease. Denial of increase personal care aide (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan has approved PCA (personal care aide) live-in services.

Answer: The patient's Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total assistance with housework and locomotion; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, toileting, and bed mobility; extensive assistance with eating; and limited assistance with phone use. He has a Foley catheter due to urinary retention. He has infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating.

Answer: There is an appeal letter from the patient's provider that notes that the patient has been admitted to hospice within the last several months. The patient is bedbound. He is noted to be more disoriented. He is not able to reposition himself, which places him at risk for skin breakdown. He requires full assistance with all ADLs (activities of daily living). He needs repositioning every two hours while in bed. He has unscheduled needs throughout the nighttime.

Answer: The patient has advanced Parkinson's disease with dementia. He is in hospice care. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with all ADLs (activities of daily living) and personal care. Compared to UAS (Uniform Assessment System) evaluation completed o previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating. The appeal letter notes the patient is bedbound and requires assistance with all ADLs (activities of daily living) and personal care as well as repositioning every 2 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. He requires total care and frequent repositioning.

Context:
Diagnosis: Parkinson's disease; osteoarthritis.
Treatment: Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).
The insurer denied the Increase Personal Care Aide (PCA) Services For A Total Of 168 Hours Per Week (split shift).
The denial is overturned.

The patient is a male. His medical conditions include Parkinson's disease, dementia, diabetes, osteoarthritis, and heart disease. Denial of increase personal care aide (PCA) services for a total of 168 hours per week, split shift, is being appealed. The plan has approved PCA (personal care aide) live-in services.

The patient's Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total assistance with housework and locomotion; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, personal hygiene, dressing, walking, toileting, and bed mobility; extensive assistance with eating; and limited assistance with phone use. He has a Foley catheter due to urinary retention. He has infrequent bowel incontinence. Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating.

There is an appeal letter from the patient's provider that notes that the patient has been admitted to hospice within the last several months. The patient is bedbound. He is noted to be more disoriented. He is not able to reposition himself, which places him at risk for skin breakdown. He requires full assistance with all ADLs (activities of daily living). He needs repositioning every two hours while in bed. He has unscheduled needs throughout the nighttime.

Yes, the requested increase in Personal Care Aide services to 24 hours/day, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. He is appealing denial of increase PCA (Personal Care Aide) services for a total of 168 hours per week, split shift. The plan has approved PCA (Personal Care Aide) live-in services.

The patient has advanced Parkinson's disease with dementia. He is in hospice care. UAS (Uniform Assessment System) evaluation completed shows the patient needs assistance with all ADLs (activities of daily living) and personal care. Compared to UAS (Uniform Assessment System) evaluation completed o previously, there has been a decline in functional status with walking, locomotion, bed mobility and eating. The appeal letter notes the patient is bedbound and requires assistance with all ADLs (activities of daily living) and personal care as well as repositioning every 2 hours. This patient has significant physical impairments that have progressed between UAS (Uniform Assessment System) evaluations. He requires total care and frequent repositioning. These needs do not permit five hours daily of uninterrupted sleep during the aide's shift. The approved PCA (Personal Care Aide), live-in, is inadequate to meet the patient's needs for assistance with ADLs (activities of daily living)/IADLs (instrumental activities of daily living). The requested increase in PCA (Personal Care Aide) for a total of 168 hours per week, split shift is medically necessary.

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


Answer: this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD)  index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.

Answer: Diagnosis: Malocclusion.

Answer: Treatment: Comprehensive Orthodontic Treatment.

Answer: The insurer denied coverage for comprehensive orthodontic treatment

Answer: the patient exhibits a malocclusion.

Answer:
In this case, the treating orthodontist claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage.

Context:
Diagnosis: Malocclusion.
Treatment: Comprehensive Orthodontic Treatment.

The insurer denied coverage for comprehensive orthodontic treatment

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral. clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD)  index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 10 points (4 points overjet, 4 points overbites, 2 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies referenced below.

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The insurer's denial of coverage for the comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated.

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


Answer: The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.

Answer: Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes

Answer: Treatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week

Answer: The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week

Answer: Cognitive skills are described as "severely impaired." She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke

Context:
Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes

Treatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week

The denial is overturned

The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.

According to the Uniform Assessment System (UAS) report , the patient has significant cognitive deficits.  Cognitive skills are described as "severely impaired." She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke, this supports the medical necessity of personal care assistance (PCA) 24hours per day, 7 days per week split shift, to allow her to resume living safely at home.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).

The requested increase Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.

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


Answer: The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

Answer: Diagnosis: Allergic reaction.

Answer: Treatment: Inpatient Hospital Stay.

Answer: The insurer denied the Inpatient Hospital Stay.

Answer: This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling.

Context:
Diagnosis: Allergic reaction.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling. There was no actual or impending airway compromise, unstable vital signs, hypoxia, respiratory distress or respiratory failure, progression of allergic reaction/angioedema while undergoing treatment, hypotension, acute coronary syndrome (ACS), hoarseness or need for IV vasopressors. Overall, this stable patient was treated with IV steroids, IM epinephrine, and antihistamines, and responded to the treatment in the ED, and these interventions could have been safely provided at a lower level of care than inpatient.

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


Answer: Diagnosis: Plantar fasciitis.

Answer: Treatment: Custom Shoe Inserts (L3000 x2).

Answer: The insurer denied coverage for Custom Shoe Inserts (L3000 x2).

Answer: The patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain.

Answer: the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended.

Context:
Diagnosis: Plantar fasciitis.
Treatment: Custom Shoe Inserts (L3000 x2).

The insurer denied coverage for Custom Shoe Inserts (L3000 x2).

The denial is overturned.

The patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain. Furthermore, the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended.

A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis. While some patients may benefit from over-the-counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available that the prefabricated orthotics made little difference and the patient needs a good custom orthotic to help with her plantar fasciitis by providing her more support. Given the available literature on this topic and this patients history, in this reviewer's expert opinion it is best that the orthotics are approved, so that the patient can get the treatment she needs to resolve her plantar fasciitis.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Custom Shoe Inserts (L3000 x2) is overturned. Medical Necessity is substantiated.

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


Answer:
This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.
At issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.

Answer: Diagnosis: Orthopedic/Musculoskeletal.

Answer: Treatment: Durable Medical Equipment (DME).

Answer: The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories.

Answer: the occupational therapist has provided a letter stating medical necessity

Context:
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Durable Medical Equipment (DME).
The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories.
The denial is upheld.

This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.
At issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.

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

The requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary for this patient.
Based on the patient's diagnosis and documentation, it is not clear that the requested items are medically necessary, as patients with Down Syndrome can have varying degrees of hypotonia. Although the occupational therapist has provided a letter stating medical necessity, there is no documentation of current status or the degree of impairment. Based on the records provided, it is not clear that the Durable Medical Equipment - Pediatric tilt wheelchair with accessories is considered medically necessary.
Therefore, the requested health service/treatment of Durable Medical Equipment-Pediatric tilt wheelchair with accessories is not medically necessary.

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


Answer:
Diagnosis: Autism
Treatment: Occupational Therapy
The insurer denied the Occupational Therapy.

Answer: The patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.

Answer: Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home.

Context:
Diagnosis: Autism
Treatment: Occupational Therapy
The insurer denied the Occupational Therapy.
The determination is upheld.

The patient received occupational therapy with treatments focusing on improving regulation and decreasing internal distractions, improving attention/focus, and decreasing thumb sucking along with balance and coordination skills.   At issue is the medical necessity of the requested occupational therapy services.

The requested occupational therapy sessions were not medically necessary for this patient.
The patient's therapy progress note documentation does not support medical necessity for the standards of practice for occupational therapy. Occupational therapy (OT) is medically necessary when there is documentation that it is improving a patient's current condition or preventing or slowing further deterioration of the patient's condition or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice.
No indication of objective measures of improvement are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.
Activities identified in the OT summary report which can be done by caregivers/parents include working with home exercise on the goals of : bear weight on upper extremities for 60 seconds, improving ball skills of throwing, catching, kicking with good force and gradation so he can participate with age appropriate ball activities, maintaining quadruped position.  Per the documentation the patient's mother is continuously involved in exercises and the treatment plan including carryover at home.  Therefore, the requested occupational therapy is not medically necessary.

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


Answer: The member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.

Answer: Diagnosis: Migraine Headache

Answer: Treatment: Emgality

Answer: The insurer denied the Emgality.

Answer: The patient has tried and failed a

Answer: trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters).

Context:
Diagnosis: Migraine Headache
Treatment: Emgality
The insurer denied the Emgality.
The denial is overturned.

The member is a female with migraine headache disorder. She is currently treated with topiramate and Emgality for migraine prevention. The provider is requesting continuation of Emgality.

Yes, the requested Emgality is medically necessary.

The patient has tried and failed a reasonable trial of topiramate for migraine prevention. She cannot be treated with divalproex sodium, as she is a female of childbearing age. She cannot be treated with amitriptyline or venlafaxine, as she is currently treated with escitalopram. She cannot be treated with a beta-blocker (Danesh and Gottschalk), as the medical records indicate relative bradycardia (heart rate 58 and 67 at two encounters). Therefore, she has either tried and failed or has a contraindication to all of the preferred agents (Burch).

Therefore, given the above, the requested Emgality is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

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


Answer: This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol.

Answer: In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications.

Answer: Diagnosis: Hypertension.

Answer: Treatment: Bystolic 5 milligram (mg) tab.

Answer: The insurer denied coverage for Bystolic 5 mg tab.

Context:
Diagnosis: Hypertension.
Treatment: Bystolic 5 milligram (mg) tab.

The insurer denied coverage for Bystolic 5 mg tab. The denial is overturned.

This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol.

Based on the information provided, the formulary medication (nebivolol) is likely to cause an adverse reaction. In addition, the other formulary drugs have been documented to be ineffective. The requested drug has successfully controlled blood pressure for approximately a year and a half. Studies have demonstrated that a small number of individuals require use of name brand medications following use of generic formulations. (2) In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications.

The requested drug is likely to be more effective than the formulary drugs.

The insurer's denial of coverage for Formulary Exception for Bystolic 5 milligram (mg) tab is overturned.

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


Answer: The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.

Answer: Diagnosis: Vision.

Answer: Treatment: Pharmacy/Prescription Drugs.

Answer: The insurer denied Acthar Gel.

Answer: This patient has been on multiple medication including serum drops and punctual plugs without improvement.

Answer: This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement.

Context:
Diagnosis: Vision.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Acthar Gel.
The denial is overturned.

The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.

The health plan's determination is overturned.

This patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be medically necessary and appropriate as the next step in the treatment of this patient.

Acathar gel has been Food and Drug Administration (FDA) approved for patients with severe acute and chronic allergic and inflammatory processes involving the eye and its adenoma. This includes keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, and anterior segment inflammation. This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement. Acthar would be an appropriate as the next step in the treatment of this patient.

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


Answer: This patient has hypertension. Blood pressure was effectively controlled with Bystolic 10mg. The patient's doctor documents an allergic reaction to the generic form of Bystolic (nebivolol). Alternative formulary agents are documented to be ineffective in controlling blood pressure. These agents include, atenolol, bisoprolol, carvedilol, labetalol, and metoprolol.

Answer: In this case the patient has been maintained on Bystolic for several years and has noted intolerance to generic formulations and inefficacy to other formulary medications.

Answer: Diagnosis: Hypertension.

Answer: Treatment: Bystolic 5 milligram (mg) tab.

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


Answer: The patient is a male with history of keratoconjunctivitis. The treating physician would like to prescribe Acthar gel for the treatment of the patient's eye disease. The patient has symptoms of burning and pain that interfere with his life daily. He has been previously treated with Cequa, Xiidra, HydroEyes, over-the-counter (OTC) artificial tears, Lotemax, serum drops, and punctal plugs but remains symptomatic. The subject under review is the medical necessity for the Acthar gel.

Answer: Diagnosis: Vision.

Answer: Treatment: Pharmacy/Prescription Drugs.

Answer: The insurer denied Acthar Gel.

Answer: This patient has been on multiple medication including serum drops and punctual plugs without improvement.

Answer: This patient has a history of keratoconjunctivitis which has been refractive in its treatment. The patient has been on multiple medication including serum drops and punctual plugs without improvement.

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


Answer: Diagnosis: Diabetic ketoacidosis (DKA).

Answer: Treatment: Inpatient admission.

Answer: The insurer denied coverage for an inpatient admission.

Answer:
The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx).

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

This patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation.

Context:
Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx).

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

This patient was acutely ill with life threatening DKA, pneumonia (PNA), diabetic skin and soft tissue infection and a COPD exacerbation. Based on above, it was appropriate to admit this patient to the hospital for active treatment and very close monitoring. This patient was not stable to be treated in any other setting.

This patient decided to sign out against medical advice (AMA), which was not in any one's control. He was not stable at the time he absconded from the hospital.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient hospital admission is overturned. Medical Necessity is substantiated.

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


Answer:
Diagnosis: Skin Disorders.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.

Answer:
The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.
The laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.
The patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.
At issue is the medical necessity of the Inpatient Admission.

Answer: The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis

Answer: the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon.

Context:
Diagnosis: Skin Disorders.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.
The denial is overturned.

The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.
The laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.
The patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.
At issue is the medical necessity of the Inpatient Admission.

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

The requested health service/treatment of Inpatient Admission was medically necessary for this patient.
The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis which are signs of systemic inflammatory process. Additionally, the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon. The documentation supports inpatient level of care for incision and drainage, IV antibiotics and pain medications.
Simple infections are usually confined to the skin and underlying superficial soft tissues generally respond well to outpatient management. However, complicated infections typically extend into and involve the underlying deep tissues including deep abscesses, decubitus ulcers, necrotizing fasciitis, and Fournier gangrene. These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also represent complicated infections. In this case, the patient's infection extended deep into the subcutaneous tissue and was recurrent despite prior drainage. The inpatient level of care was necessary for repeat incision, drainage and IV antibiotics given the presence of purulence and systemic signs of infection.
It is widely accepted in the literature that diabetics have an increased propensity to develop infections. Hyperglycemia causes both micro- and macrovascular complications, which are known illustrated as possible mechanisms that prevent the ulcers from wound healing. Blood glucose management is therefore considered a basic component of the treatment of wound healing. In this case, the inpatient level of care is appropriate for aggressive blood glucose control and expedited wound drainage.
Therefore, the requested health service/treatment of Inpatient Admission was medically necessary.

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


Answer:
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Durable Medical Equipment (DME).
The insurer denied Durable Medical Equipment Pediatric tilt wheelchair with accessories.

Answer:
This patient is a female with Down Syndrome and severe developmental delays whose care team is requesting a Rodeo stroller with tilt, flip-up armrests, and other accessories. Letters from the patient's occupational therapist note that the patient has poor core stability and generalized hypotonia. Per the denial letter, the following criteria must be met to approve this service: medical records detailing the condition and medical necessity of the requested service, such as impaired ability to stand and walk.
At issue is the medical necessity of Durable Medical Equipment Pediatric tilt wheelchair with accessories.

Answer: the occupational therapist has provided a letter stating medical necessity

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


Answer:
Diagnosis: Skin Disorders.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.

Answer:
The patient is a female with a past medical history of diabetes, hypertension, and hyperlipidemia, who presented for abscess of the right armpit and right gluteal area. The review of systems was negative for additional clinical symptoms. The patient was febrile (a temperature of 101.5) in the emergency department (ED). She was described as comfortable and in no acute distress. Her blood pressure was 143/64, pulse rate was 82, respiratory rate was 19, and oxygen saturation was 95% (percent) on room air. The physical examination was remarkable for an erythematous area of the right axilla and right gluteal fold.
The laboratory evaluation demonstrated a blood urea nitrogen (BUN) of 14, creatinine of 0.56, white blood cell (WBC) count of 14.8, hemoglobin (Hgb) of 11.36, and hematocrit (Hct) of 36.6. The computed tomography (CT) scan of the pelvis showed developing abscess/phlegmon of the right buttock skin with subcutaneous edema.
The patient was admitted for right axillary/gluteal abscess and cellulitis. The patient underwent an incision and drainage of the abscesses. The patient was treated with intravenous (IV) vancomycin. The hospital course was notable for continued purulent drainage from the abscess site. The patient was evaluated by a general surgeon and an extension of prior axially incision and drainage (I and D) site was performed with breakage of loculations and increased drainage of purulent material. Wound and blood cultures were negative. The patient was treated with IV Ketorolac and Tylenol for pain.
At issue is the medical necessity of the Inpatient Admission.

Answer: The patient was admitted for abscesses of the axilla and gluteal areas in the setting of fever and leukocytosis

Answer: the patient did not have adequate improvement after initial incision and drainage in the ED. The patient continued to have persistent purulent drainage requiring extension of incision and drainage by the surgeon.

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


Answer:
The patient has a history of (H/O) IDDM (insulin dependent diabetes mellitus), hypertension (HTN), and hyperlipidemia (HLD).  He presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB), and R (right) sided chest pain (CP). The patient was reportedly non-compliant with his Diabetic meds. The patient also C/O a productive cough.

Vital signs at presentation were as follows: Temperature 37.3 F (Fahrenheit), Heart Rate 107, Respiratory Rate 18, Blood Pressure 169/81 mm Hg (millimeters of mercury), and Oxygen (O2) saturations 89%. The patient was tachypneic and in some distress. Physical exam revealed Rhonchi and decreased BS (bowel sounds) bilateral (B/L). The patient also had a diabetic foot ulcer and infection.

White blood cell count (WBC) was 12.8K (thousand). The patient had a BG (blood glucose) of 479 and the HbA1C (glycated hemoglobin test) was 16.7 Anion Gap was 16 B-OH (Beta-Hydroxy) butyrate was 5.5 pH (potential for hydrogen) 7.31/PCO2 (carbon dioxide) 33.

Chest x-rays revealed (CXR) revealed B/L airspace disease.

The patient was treated with intravenous (IV) fluids and IV insulin 1 dose was given in the ED (emergency department). The patient was also treated with Solumedrol, BD (bronchodilator) and BS (broad spectrum) antibiotics (Abx).

Repeat Labs came back later that evening which revealed that AG (albumin/globulin) had increased to 17. His BG was still elevated to 453.

The patient had decreased serum HCO3 (bicarbonate). At this point the patient was admitted to the intensive care unit (ICU) for management of his diabetic ketoacidosis (DKA). The patient also had sepsis secondary to pneumonia and the Diabetic foot infection. The patient was also diagnosed to have a chronic obstructive pulmonary disease (COPD) exacerbation.

Answer:
Diagnosis: Diabetic ketoacidosis (DKA).
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

Answer: This patient decided to sign out against medical advice (AMA)

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


Answer:
Diagnosis: Abdominal pain
Treatment: CT (computed tomography) scan
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis .

Answer: The patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month).

Context:
Diagnosis: Abdominal pain
Treatment: CT (computed tomography) scan
The insurer denied Computed Tomography (CT) of Abdomen and Pelvis .
The health plan's determination is overturned.

The patient is a female with history of recurrent diverticulitis and sigmoid colon resection, and lysis of adhesions. She has had constipation. She presented with significant tenderness and pain in the left lower quadrant of the abdomen. She had ongoing abdominal pain (persistent for a month).

Computed Tomography (CT) of Abdomen and Pelvis is medically necessary for this patient.

Given that a cause for ongoing abdominal pain has not been definitively determined in the patient, and CT scan has a high sensitivity for several serious etiologies for abdominal pain that cannot be discovered by physical examination or more limited imaging examinations, and given that the patient has a history of diverticulitis and may now have persistent diverticulitis or complications of diverticulitis such as abscess, the requested CT scan is medically necessary in this case.

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


Answer:
Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.

Answer:
This is a female child with a medical history significant for moderate persistent asthma, eosinophilic esophagitis, food allergies, allergic rhinitis, and eczema who presented to the emergency department (ED) with a one-day history of increased work of breathing. She had been seen in the ED earlier that day, treated with DuoNebs and steroids for an asthma exacerbation, and discharged home. She returned to the ED for persistent wheezing unresponsive to nebulized albuterol at home.
The examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, decreased air movement, wheezing, and tachypnea. She was able to speak in full sentences, with non-focal neurologic exam.
She was treated with magnesium, two DuoNebs, and a normal saline bolus. She was subsequently admitted because she remained symptomatic. Admission orders included continuous cardiopulmonary monitoring, regular diet, maintenance intravenous (IV) fluids, albuterol 2.5 milligrams (mg) every three hours, continued home medications (cetirizine, Singular), continued oral steroids.
She remained hemodynamically stable throughout the hospital stay with no need for supplemental oxygen. Albuterol was gradually weaned to every four hours. She tolerated her other medications as well as her diet.  She was deemed stable for discharge to pursue allergy testing. At issue is the medical necessity of an inpatient stay.

Answer: This female child with a complex and significant history including moderate persistent asthma presented to the ED for the second time in one day. She remained symptomatic despite aggressive care in the ED and was admitted for ongoing treatment.

Context:
Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female child with a medical history significant for moderate persistent asthma, eosinophilic esophagitis, food allergies, allergic rhinitis, and eczema who presented to the emergency department (ED) with a one-day history of increased work of breathing. She had been seen in the ED earlier that day, treated with DuoNebs and steroids for an asthma exacerbation, and discharged home. She returned to the ED for persistent wheezing unresponsive to nebulized albuterol at home.
The examination was significant for non-toxic appearance, moist mucous membranes, tachycardia, decreased air movement, wheezing, and tachypnea. She was able to speak in full sentences, with non-focal neurologic exam.
She was treated with magnesium, two DuoNebs, and a normal saline bolus. She was subsequently admitted because she remained symptomatic. Admission orders included continuous cardiopulmonary monitoring, regular diet, maintenance intravenous (IV) fluids, albuterol 2.5 milligrams (mg) every three hours, continued home medications (cetirizine, Singular), continued oral steroids.
She remained hemodynamically stable throughout the hospital stay with no need for supplemental oxygen. Albuterol was gradually weaned to every four hours. She tolerated her other medications as well as her diet.  She was deemed stable for discharge to pursue allergy testing. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is said to occur when the patient fails to respond initially to bronchodilators and other medications administered in an emergency department (ED) setting. Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.
This female child with a complex and significant history including moderate persistent asthma presented to the ED for the second time in one day. She remained symptomatic despite aggressive care in the ED and was admitted for ongoing treatment. While it was reasonable and appropriate to monitor this patient in the hospital to provide ongoing care, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at lower level of care.

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


Answer:
Diagnosis: Shortness of breath
Treatment: Hospital admission
The insurer denied coverage for an inpatient admission.

Answer:
This is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.

Vital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.

The patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline.

The patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.

The patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications.

Context:
Diagnosis: Shortness of breath
Treatment: Hospital admission
The insurer denied coverage for an inpatient admission.
The denial is upheld.

This is a patient with a history of Asthma presented to the emergency department (ED) with complaint of (C/O) shortness of breath (SOB) with productive cough and wheezing. The patient had used her inhalers at home but did not feel better so came to the ED.

Vital signs at presentation included: Temperature 98.1 degrees F (Fahrenheit) , Heart Rate 99, Respiratory Rate 18, Blood Pressure 126/72, oxygen (O2) saturation 98 % on Room Air. White blood cell count (WBC) was 9.7 K (thousand) Hb (hemoglobin) 14.3, electrolytes were within normal limits (WNL), oxygen saturation was 92-93 % on room Air, chest x-ray was negative. COVID-19 (coronavirus disease 2019) and Influenza were negative.

The patient was noted to have bilateral (B/L) wheezing and was given Decadron intravenous (IV) 10 mg (milligrams), Magnesium sulfate, and DuoNebs. She did show improvement but as she was still wheezing, she was admitted to the hospital with acute exacerbation of asthma. Per the history and physical (H&P), the patient was in no acute distress (NAD), was afebrile, and hemodynamically stable. A lung exam showed a bilateral wheeze. The patient was switched to Solumedrol 60 mg and continued on nebulizers and Doxycycline.

The patient was in no distress with stable vital signs: Temperature 98 degrees F (Fahrenheit), Heart Rate 91, Respiratory Rate 17, Blood Pressure 113/65, oxygen (O2) saturation 98% on Room Air. No evidence of CO2 (carbon dioxide) retention.

The patient was not hypoxic, was hemodynamically stable, not using accessory muscles and was speaking in full sentences. No pneumonia (PNA) on the CXR (chest x-ray). The patient was stable to be switched to oral steroids and other medications. The patient could have been treated under observation status for up to 48 hours. She remained stable after admission and did not need acute inpatient hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the hospital admission is not substantiated.

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


Answer:
Diagnosis: Nodular scleritis and recurrent bilateral anterior uveitis
Treatment: Acthar Gel
The insurer denied the Acthar Gel.

Answer:
The patient is a female with a history of nodular scleritis and recurrent bilateral anterior uveitis for whom coverage of Acthar Gel is the subject of review. Coverage was previously denied coverage by the health plan, as current plan-approved criteria do not allow coverage of Acthar Gel unless the patient has a diagnosis of infantile spasms or multiple sclerosis. Alternatives on the plan's formulary are identified as dexamethasone, prednisolone, methylprednisolone, hydrocortisone, and prednisone. The plan requires a trial of 3 alternatives if there are 3 or more covered alternatives.

The patient is identified as having Ankylosing Spondylitis and Crohn's disease which have been causing severe eye inflammation with extreme flare-ups about every 3 months and/or scleritis for the past 14 years despite receiving systemic treatment for her rheumatologic disease. The patient is currently being treated with Humira (adalimumab) and has tried and failed samples of prednisolone, atropine, and Durezol.

Context:
Diagnosis: Nodular scleritis and recurrent bilateral anterior uveitis
Treatment: Acthar Gel
The insurer denied the Acthar Gel.
The denial is overturned.

The patient is a female with a history of nodular scleritis and recurrent bilateral anterior uveitis for whom coverage of Acthar Gel is the subject of review. Coverage was previously denied coverage by the health plan, as current plan-approved criteria do not allow coverage of Acthar Gel unless the patient has a diagnosis of infantile spasms or multiple sclerosis. Alternatives on the plan's formulary are identified as dexamethasone, prednisolone, methylprednisolone, hydrocortisone, and prednisone. The plan requires a trial of 3 alternatives if there are 3 or more covered alternatives.

The patient is identified as having Ankylosing Spondylitis and Crohn's disease which have been causing severe eye inflammation with extreme flare-ups about every 3 months and/or scleritis for the past 14 years despite receiving systemic treatment for her rheumatologic disease. The patient is currently being treated with Humira (adalimumab) and has tried and failed samples of prednisolone, atropine, and Durezol.

The health plan should cover the formulary exception for Acthar Gel.

Chronic use of formulary systemic steroids would place the patient at unnecessary risk and run counter to the standard of care, as the patient has already moved on to steroid-sparing agents. According to the package insert, H.P. (highly purified) Acthar Gel may be used for ophthalmic diseases. In this case, Acthar is proposed for the treatment of nodular scleritis and recurrent bilateral anterior uveitis that has been refractory to topical steroids (prednisolone, Durezol), immunosuppressive therapy (methotrexate), and biologics (Humira).

Several case reports are identified in the peer-reviewed medical literature that supports the safety and efficacy of Acthar in the treatment of such non-infectious uveitis. Agarwal et al recently published a case report describing the potential role of subcutaneously administered ACTH (adrenocorticotropic hormone) gel in the management of a patient with non-infectious panuveitis with significant retinal vasculitis, macular edema, and optic nerve inflammation. Therapy with ACTH (adrenocorticotropic hormone) gel resulted in rapid and adequate control of retinal vascular leakage, macular edema, and optic nerve inflammation.

In a second case report by Ahmad et al, a 16-year-old female with recurrent uveitis associated with poorly controlled juvenile idiopathic arthritis reported remission of uveitis symptoms after receiving RCI (repository corticotropin injection) (80U [units] administered intramuscularly 2 times per week) as additive therapy.

Sharon et al. reported the clinical course of three patients with bilateral, non-infectious anterior, and intermediate uveitis, treated with ACTH (adrenocorticotropic hormone) gel for 12 months. The authors concluded that subcutaneous adrenocorticotropic hormone gel has shown to be a safe and effective therapy in the management of non-infectious uveitis.

Nelson et al performed a retrospective medical records review of patients who had a diagnosis of uveitis, received repository corticotropin injection (RCI) in the prior 12 months, and had completed or were receiving RCI (repository corticotropin injection) treatment at the time of data collection. The author concluded that physicians individualized RCI (repository corticotropin injection) therapy among patients who suffered uveitis for several years and when previous therapies were inadequate. Most patients improved after initiating RCI (repository corticotropin injection), most commonly in vision. As uveitis is usually treated with a stepwise approach using corticosteroids, immunosuppressive therapy, and biologics, and this patient has failed or been intolerant to each of these therapies, the medical necessity of Acthar is established in this case.

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


Answer:
Diagnosis: Spasticity at the ankle
Treatment: Durable Medical Equipment -flexion/extension device
The health plan denied the Durable Medical Equipment as not medically necessary.

Answer: This is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching.

Context:
Diagnosis: Spasticity at the ankle
Treatment: Durable Medical Equipment -flexion/extension device
The health plan denied the Durable Medical Equipment as not medically necessary.
The health plan's determination is upheld.

This is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching.

The ankle Dynasplint is not medically necessary for this patient with spasticity at the ankle.

Standard of care for spasticity in the spinal cord population includes toxin injection with aggressive range of motion and splinting. Treatment for this condition includes a toxin injection and an ankle-foot orthosis (AFO)/multipodus boot.

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


Answer:
Diagnosis: Gastroesophageal reflux disease (GERD)
Treatment: Transoral incisionless fundoplication (TIF)
The insurer denied transoral incisionless fundoplication (TIF).

Answer: The patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD.

Context:
Diagnosis: Gastroesophageal reflux disease (GERD)
Treatment: Transoral incisionless fundoplication (TIF)
The insurer denied transoral incisionless fundoplication (TIF).
The determination is overturned.

The patient has gastroesophageal reflux disease (GERD). He has failed proton pump inhibitor therapy for multiple years, as well as pantoprazole 40 milligrams (mg) daily with famotidine 40 mg daily. An esophagogastroduodenoscopy showed unremarkable esophagus, a small hiatal hernia, patchy gastritis, gastric polyps, and unremarkable duodenum; gastroesophageal junction biopsies showed mild chronic inflammation. Esophageal manometry was normal. At issue is the medical necessity of transoral incisionless fundoplication (TIF) for the treatment of GERD.

The requested TIF is medically necessary. The efficacy of TIF using the EsophyX device has been studied in a meta-analysis including 3 randomized controlled trials (including 233 patients at 3 years), with findings of improved esophageal potential hydrogen (pH), decreased proton pump inhibitor utilization, and improved quality of life compared with proton pump inhibitor therapy of sham treatment [1-4]. The American College of Gastroenterology (ACG) guidelines for the treatment of GERD state that "We suggest consideration of transoral incisionless fundoplication (TIF) for patients with troublesome regurgitation or heartburn who do not wish to undergo anti-reflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias greater than (>) 2 centimeters (cm)." In this case, the patient does not have severe reflux esophagitis or hiatal hernia larger than 2 cm [5]. Additionally, the patient has attempted therapy with a proton pump inhibitor, as recommended by ACG guidelines, without improvement in symptoms and concurrent gastroesophageal junction inflammation on endoscopic biopsies. For these reasons, the use of transoral incisionless fundoplication is supported as medically necessary for the treatment of this patient's GERD.

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


Answer:
Diagnosis: Coronary Artery Disease
Treatment: Inpatient day
The insurer denied coverage for inpatient day

Answer:
This elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day.

Context:
Diagnosis: Coronary Artery Disease
Treatment: Inpatient day
The insurer denied coverage for inpatient day
The denial is upheld.

This elderly woman presented to the hospital for elective cardiac catheterization due to worsening of dyspnea on exertion. Past medical history was significant for hypertension and diabetes mellitus. She was noted to have a positive stress test. Cardiac catheterization was performed and revealed a left anterior descending artery stenosis. A drug eluting stent was successfully deployed. There were no perioperative complications, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. She underwent an uncomplicated procedure, and a drug eluting stent was placed in the left anterior descending (LAD) artery. She was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference 1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care (Reference 4). In conclusion, inpatient admission was not medically necessary. The patient could have been managed at a lower level of care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient day is upheld. Medical Necessity is not substantiated.

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