Answer: The patient  has multiple medical problems but most notably dementia of Alzheimer's type. The patient requests 24 hour a day split shift personal care aide. The patient previously has been approved for a live-in aide

Context:
The patient  has multiple medical problems but most notably dementia of Alzheimer's type. The patient requests 24 hour a day split shift personal care aide. The patient previously has been approved for a live-in aide.The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of 24 Hour/7 Days Split Shift per Week Personal Care Aide is not medically necessary for this patient. There was not a significant change in the medical necessity for additional services from the first assessment to the second assessment.
These services can be performed within the 84 hours allotted for the week.

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


Answer: Diagnosis: Pneumonia vs. Bronchitis.

Answer: Treatment: inpatient admission

Answer: The insurer denied coverage inpatient admission.

Answer: This patient is a female with past medical history (PMH) of: hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) - non compliant with bilevel positive airway pressure (BIPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) over the past several days. The patient's nebulizer machine at home was broken. The patient has history of multiple intubations in the past for COPD exacerbations. The patient still smokes 3-5 cigarettes/day. The patient had been also suffering from some upper respiratory tract infection (URTI) symptoms. The patient also complained of some palpitations.

Answer: The vital signs at presentation in ER were: blood pressure (BP) 156/89, respiratory rate (RR) 22, heart rate (HR) 102 and oxygen saturations were 86 %. The vital signs per Emergency Department Medical Doctor (MD) were temperature 98.7, respiratory rate (RR) 20, blood pressure (BP) 120/72 mm Hg and oxygen saturation at 100%. The patient was in no acute distress (NAD).  Lungs had mild respiratory distress and bilateral basal rales. The cardiovascular system (CVS) S1 S2 was normal (N). There was no jugular venous distention (JVD).  The abdomen was soft and nontender (NT).

Answer: As per the History & Physical the patient was afebrile and vital signs (VSS) stable. The patient was saturating 100% on nasal cannula. There was no use of accessory muscles. There was mild wheeze. The cardiovascular system (CVS) S1 S2 was normal. The admitting diagnosis was COPD exacerbation likely from Acute Bronchitis. The patient's peak expiratory flow (PEF) was 170 (Baseline 200). The chest x-ray was unremarkable. The computer tomogram (CT) indicates - chest right lower lobe (RLL) infiltrates or Pneumonia. The arterial blood gas (ABG on 2L) was 7.37/68/52/38/ 86 %. This is close to her baseline. The plan was to continue on steroids, bronchodilator, Azithromycin and BIPAP at night with 10/5 setting.

Context:
Diagnosis: Pneumonia vs. Bronchitis.

Treatment: inpatient admission

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

This patient is a female with past medical history (PMH) of: hypertension (HTN), chronic obstructive pulmonary disease (COPD) on home oxygen, obstructive sleep apnea (OSA) - non compliant with bilevel positive airway pressure (BIPAP). The patient presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) over the past several days. The patient's nebulizer machine at home was broken. The patient has history of multiple intubations in the past for COPD exacerbations. The patient still smokes 3-5 cigarettes/day. The patient had been also suffering from some upper respiratory tract infection (URTI) symptoms. The patient also complained of some palpitations.

The vital signs at presentation in ER were: blood pressure (BP) 156/89, respiratory rate (RR) 22, heart rate (HR) 102 and oxygen saturations were 86 %. The vital signs per Emergency Department Medical Doctor (MD) were temperature 98.7, respiratory rate (RR) 20, blood pressure (BP) 120/72 mm Hg and oxygen saturation at 100%. The patient was in no acute distress (NAD).  Lungs had mild respiratory distress and bilateral basal rales. The cardiovascular system (CVS) S1 S2 was normal (N). There was no jugular venous distention (JVD).  The abdomen was soft and nontender (NT).

As per the History & Physical the patient was afebrile and vital signs (VSS) stable. The patient was saturating 100% on nasal cannula. There was no use of accessory muscles. There was mild wheeze. The cardiovascular system (CVS) S1 S2 was normal. The admitting diagnosis was COPD exacerbation likely from Acute Bronchitis. The patient's peak expiratory flow (PEF) was 170 (Baseline 200). The chest x-ray was unremarkable. The computer tomogram (CT) indicates - chest right lower lobe (RLL) infiltrates or Pneumonia. The arterial blood gas (ABG on 2L) was 7.37/68/52/38/ 86 %. This is close to her baseline. The plan was to continue on steroids, bronchodilator, Azithromycin and BIPAP at night with 10/5 setting.

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment initiated. The patient was close to her baseline after initial treatment. Pneumonia if present was mild. The white blood cell count (WBC) was normal. There was no fever. The partial oxygen (PaO2) was close to baseline. The CURB 65 score 0. The patient could have been switched to oral steroids and bronchodilators and oral antibiotics after a period in Observation and then subsequently discharged home with close follow-up in an outpatient setting. The prior denial was appropriate.

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.

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


Answer: The patient has a past medical history significant for hypertension, bronchitis, gastroesophageal reflux disease (GERD), tobacco abuse, and cocaine abuse who presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and anorexia for 4 days. At the time of admission, the patient  was unable to tolerate any liquids or solid food. The patient reported an intermittent lower abdominal cramping pain, which he described as 2-3/10 in intensity. The pain resolved spontaneously, and each bout lasted for 10-15 minutes. At the time of initial evaluation, the patient denied diarrhea and stated that the last bowel movement was 2 days before the day of admission.

Answer: At the time of admission the patient denied any fever, chills, dysphagia, odynophagia, dyspepsia, bloating, hematemesis, melena, or fresh blood in the stool. The patient was afebrile, blood pressure was 129/78, pulse rate 72 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient had mild tenderness around the umbilicus without rebound tenderness. He also had an itchy scaly rash on the hands. The rest of the physical exam was unremarkable. Abdominal x-ray showed nonspecific bowel gas pattern. Subsequent computed tomography (CT) scan of the abdomen and pelvis did not reveal any significant abnormalities in the abdomen. The patient was admitted to the hospital with a diagnosis of abdominal pain and vomiting, which was attributed to acute gastroenteritis. It was indicated that the patient's electrolytes were within normal limits.

Answer: This patient's hospital stay was very short. The patient responded to the supportive care provided and was discharged from the hospital. In the records submitted the Milliman Care Guidelines criteria for gastroenteritis is referenced.

Context:
The patient has a past medical history significant for hypertension, bronchitis, gastroesophageal reflux disease (GERD), tobacco abuse, and cocaine abuse who presented to the emergency department with complaints of abdominal pain, nausea, vomiting, and anorexia for 4 days. At the time of admission, the patient  was unable to tolerate any liquids or solid food. The patient reported an intermittent lower abdominal cramping pain, which he described as 2-3/10 in intensity. The pain resolved spontaneously, and each bout lasted for 10-15 minutes. At the time of initial evaluation, the patient denied diarrhea and stated that the last bowel movement was 2 days before the day of admission.
At the time of admission the patient denied any fever, chills, dysphagia, odynophagia, dyspepsia, bloating, hematemesis, melena, or fresh blood in the stool. The patient was afebrile, blood pressure was 129/78, pulse rate 72 beats per minute (bpm), respiratory rate 18, oxygen saturation 98% on room air. The patient had mild tenderness around the umbilicus without rebound tenderness. He also had an itchy scaly rash on the hands. The rest of the physical exam was unremarkable. Abdominal x-ray showed nonspecific bowel gas pattern. Subsequent computed tomography (CT) scan of the abdomen and pelvis did not reveal any significant abnormalities in the abdomen. The patient was admitted to the hospital with a diagnosis of abdominal pain and vomiting, which was attributed to acute gastroenteritis. It was indicated that the patient's electrolytes were within normal limits. The requested health service/treatment of inpatient stay was not medically necessary for this patient, since neither the severity of the patient's condition nor the complexity of services provided justified acute inpatient level of care. Most likely, according to the records submitted for review, the patient had acute gastroenteritis, which is usually a self-limited condition and mostly requires supportive care only. This patient's hospital stay was very short. The patient responded to the supportive care provided and was discharged from the hospital. In the records submitted the Milliman Care Guidelines criteria for gastroenteritis is referenced.  The patient had none of the circumstances listed above qualifying for an inpatient hospital stay. There was no need for any invasive procedures or diagnostic studies necessitating admission at the acute inpatient level of care. The patient could have received treatment at a lower level of care.
The health plan's determination of medical necessity is upheld in whole.

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


Answer: The patient presented with vomiting and abdominal pain. She was afebrile and vital signs were stable. The patient had abdominal guarding but no peritoneal signs. There was no leukocytosis. The pancreatic enzymes were mildly elevated. A sonogram did not show evidence of acute pancreatitis. The abdominal pain improved and the patient was able to tolerate a diet. Proton Pump Inhibitor (PPI) therapy was given for alcoholic gastritis. The patient was discharged and advised to avoid alcohol.

Answer: Diagnosis: Pancreatitis versus gastritis

Answer: Treatment: Inpatient admission, medication, monitoring

Answer: The insurer denied the inpatient admission.

Context:
Diagnosis: Pancreatitis versus gastritis

Treatment: Inpatient admission, medication, monitoring

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

The patient presented with vomiting and abdominal pain. She was afebrile and vital signs were stable. The patient had abdominal guarding but no peritoneal signs. There was no leukocytosis. The pancreatic enzymes were mildly elevated. A sonogram did not show evidence of acute pancreatitis. The abdominal pain improved and the patient was able to tolerate a diet. Proton Pump Inhibitor (PPI) therapy was given for alcoholic gastritis. The patient was discharged and advised to avoid alcohol.

Clinical Indications for admission for pancreatitis (M-250) include having acute pancreatitis as manifested by 2 factors including abdominal pain, pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. This patient did not have pancreatic enzymes greater than 3 times the upper limit of normal or characteristic imaging. She also did not have hemodynamic instability, hypoxemia, acute renal failure, or a severe electrolyte abnormality.

Clinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, and vomiting that is persistent. The patient did not have these conditions. The vomiting resolved after treatment in the emergency room.

This patient had alcoholic gastritis and mildly elevated pancreatic enzymes. Intravenous (IV) hydration, PPI therapy, and antiemetics could have been given in the ER. She did not meet MCG criteria for admission for either pancreatitis or gastritis. She could have been managed with observation status.

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

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


Answer: This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.

Answer: At the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia.

Context:
This is a patient with a past medical history significant for uterine fibroids, goiter, and hemorrhoids who was referred to the emergency department by her primary care physician because of anemia. At the time of the initial evaluation, the patient denied any injury, overt bleeding, or blood in the stool or urine. She denied any excessive bleeding or bleeding between the menstrual cycles. The review of systems was positive for generalized weakness, otherwise negative.
At the time of the initial evaluation patient's temperature was 99.1 degrees Fahrenheit (F), pulse rate 105, respiratory rate 19, blood pressure 125/56, and oxygen saturation was 100% on room air. The rest of the physical exam was unremarkable. An EKG demonstrated normal sinus rhythm, no evidence of ischemia.
The health plan's determination is upheld. The inpatient admission was not medically necessary. A fecal occult blood test was negative. Anemia workup was initiated. The patient was ordered infusion of two units of packed red blood cells. During the hospital stay, the patient remained afebrile and hemodynamically stable. It was noted in the discharge summary that the patient's anemia was most likely due to iron deficiency. It was also noted that the etiology was still unknown at the time of discharge. The patient had no active massive hemorrhage, active hemolysis or rapidly progressive anemia, hemodynamic instability, cardiovascular symptoms such as dyspnea, chest pain. There was no evidence of heart failure, neurologic symptoms, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, or any other conditions necessitating admission at the inpatient level of care. There was no need for any procedures or diagnostic tests necessitating inpatient level of care.

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


Answer: The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair.

Context: The patient has a past medical history significant for recurrent diabetic foot ulcers with right toe amputation due to osteomyelitis, neuropathies, obesity, cerebrovascular accident (CVA) with left sided hemiparesis and non-ST elevation myocardial infarction (NSTEMI). Request is for a power wheelchair.  Power Wheelchair is not medically necessary for this patient. Provider notes that the patient is able to use a walker in the home. The use of an electric scooter/wheelchair outside of the home is not appropriate. If the patient is able to use a walker in the home patient should be capable of using a manual wheelchair outside of the home. Therefore, a customized manual wheelchair is more appropriate and within the generally accepted standards of medical care. The HP determination is upheld.

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


Answer: The patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement.

Answer: Diagnosis: Back and neck pain

Answer: Issue under review: Increase in consumer directed personal care assistance services

Context:
Diagnosis: Back and neck pain
Issue under review: Increase in consumer directed personal care assistance services

Determination:
The Increase in consumer directed personal care assistance services is medically necessary.

The patient has a history of chronic low back and neck pain. Due to these conditions, she has difficulty ambulating with associated gait ataxia, frequent falls and difficulty completing her activities of daily living (ADLs). Furthermore, her chronic musculoskeletal pain and decreased range of motion have rendered her chronically homebound, as she is unable to sit/stand/walk for prolonged periods of time longer than 20 to 30 minutes. In addition, she is restricted from bending/pushing/crouching/squatting/stooping and lifting/carrying greater than 10 lbs, per functional assessment statement. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance services from 30 to 40 hours per week is deemed medically necessary.

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


Answer: Diagnosis: Liver Disease/Fatty Liver

Answer: Treatment: Magnetic Resonance Imaging, Abdomen

Answer: The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver.

Context:
Diagnosis: Liver Disease/Fatty Liver
Treatment: Magnetic Resonance Imaging, Abdomen

Summary:
No, the proposed MRI abdomen/MRCP is not appropriate and medically necessary for the evaluation and management of fatty liver and simple liver cyst. The patient has mild elevation of ALT due to underlying fatty liver disease. She had an MRI of the abdomen in December 2016, which revealed fatty liver disease and a small 3mm cyst in the right lobe of the liver. There was no evidence of biliary disease/obstruction/ or primary sclerosing cholangitis (PSC). Since there is no evidence of biliary obstruction or biochemical evidence of cholestasis (intra- or extra-hepatic cholestasis) based upon the liver function tests, no further evaluation is required.

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


Answer: This is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.

Answer: Diagnosis: Melanoma

Answer: Treatment: The DecisionDX-Melanoma Assay test

Answer: The insurer denied the  DecisionDX-Melanoma Assay test.

Context:
Diagnosis: Melanoma

Treatment: The DecisionDX-Melanoma Assay test

The insurer denied the  DecisionDX-Melanoma Assay test. The denial was upheld.

This is a male patient with a history of Melanoma. According to his surgical pathology report, he had a melanoma 2.3 millimeter thickness and a basal cell carcinoma on the left side of his forehead. As recommended, the patient underwent further testing for his diagnosis. The test revealed that the patient was a low risk for a reoccurrence.

The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma. However, the test is still investigational and is not the standard of care. According to the National Comprehensive Cancer Network (NCCN), routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study.  Given that the current recommendations at this time do not include the use of DecisionDX gene expression testing and the current peer-reviewed literature shows studies are needed to identify the clinical utility of such testing, the DecisionDX UM testing is not medically necessary.

Based on the above, the medical necessity for the Decision DX-Melanoma Assay test is not substantiated.  The insurer's denial is upheld.

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


Answer:
Diagnosis: Severe bronchopulmonary dysplasia
Treatment: Continued inpatient stay

Answer: This is the case of a boy that was born premature at 23 weeks gestation that is medically fragile due to multiple medical problems.  He is ventilator dependent full time due to severe bronchopulmonary dysplasia with chronic respiratory failure.  He has microcephaly and a history of grade 3 intraventricular hemorrhage at birth.  He had a history of a right hemothorax, seizures, retinopathy of prematurity with vision defects, congenital hearing loss, kidney stones, hydronephrosis, pulmonary hypertension, acute drug withdrawal, and dysautonomia. He has profound developmental delays. His most recent admission to the Hospital was following an acute hospital admission for treatment of a perianal abscess.  He reportedly had four prior admissions to the Hospital due to his medically fragile state.  The discharge plan was for this child to be sent to a skilled nursing facility when medically stable.  Reportedly, the child's family was unwilling and felt that they were unable to care for him.  The clinical notes from the Hospital document that over the time in question, no skilled nursing facility bed became available for this child and he remained in need of 24-hour ventilation, skilled nursing care, gastrostomy feeding, multiple medications, and habilitative services.

Answer: He is diagnosed with bronchopulmonary dysplasia, microcephaly, and pulmonary hypertension.

Context:
Diagnosis: Severe bronchopulmonary dysplasia
Treatment: Continued inpatient stay

The proposed treatment is medically necessary based on the patient's complicated medical condition, his medically fragile state, and the New York State Guidelines (Attachment G: Office of Health Insurance Programs Principles for Medically Fragile Children).  The guidelines state the following: A "medically fragile child" is defined as an individual under 21 years of age who has a chronic debilitating condition or conditions who may or may not be hospitalized who meets the following criteria:
1) Is technologically dependent for life or health sustaining functions;
2) Requires a complex medication regimen or medical interventions to maintain or to improve their health status;
3) Is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at risk.

"Chronic debilitating conditions include, but are not limited to, bronchopulmonary dysplasia, cerebral palsy, congenital heart disease, microcephaly, pulmonary hypertension, and muscular dystrophy."

This is the case of a boy that was born premature at 23 weeks gestation that is medically fragile due to multiple medical problems.  He is ventilator dependent full time due to severe bronchopulmonary dysplasia with chronic respiratory failure.  He has microcephaly and a history of grade 3 intraventricular hemorrhage at birth.  He had a history of a right hemothorax, seizures, retinopathy of prematurity with vision defects, congenital hearing loss, kidney stones, hydronephrosis, pulmonary hypertension, acute drug withdrawal, and dysautonomia. He has profound developmental delays. His most recent admission to the Hospital was following an acute hospital admission for treatment of a perianal abscess.  He reportedly had four prior admissions to the Hospital due to his medically fragile state.  The discharge plan was for this child to be sent to a skilled nursing facility when medically stable.  Reportedly, the child's family was unwilling and felt that they were unable to care for him.  The clinical notes from the Hospital document that over the time in question, no skilled nursing facility bed became available for this child and he remained in need of 24-hour ventilation, skilled nursing care, gastrostomy feeding, multiple medications, and habilitative services.

The patient in this case meets the definition of a medically fragile child.  He is diagnosed with bronchopulmonary dysplasia, microcephaly, and pulmonary hypertension.  He likely has an additional diagnosis of cerebral palsy based on his medical history and description of his neuromuscular examination.  He could not be safely discharged to a home setting with his complex medical needs.  A skilled nursing facility level of care was necessary for him but the discharge remains prolonged due to the lack of an available bed for him.  In the interim, the child is undergoing ongoing medical treatment to reduce the number of his sedating medications, wean him from the ventilator, and provide habilitative services to optimize his functional development.

The patient in this case requires 24-hour nursing care due to his ventilator dependence and complicated medicine regimen.  His fragile condition requires frequent medical decision making to treat signs and symptoms of dysautonomia that can result in further brain damage if not properly treated.  The patient could not be safely discharged to a lower level of care without the necessary skilled nursing, medical equipment, and safe space for the child to be treated.  The treating hospital clearly documented that the patient was awaiting a bed in an appropriate skilled nursing facility and that no bed had become available.

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


Answer: This is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.

Answer: Diagnosis: Syncope versus seizure

Answer: Treatment: Brain magnetic resonance angiography

Answer: The insurer denied the brain magnetic resonance angiography.

Answer: The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection.

Context:
Diagnosis: Syncope versus seizure

Treatment: Brain magnetic resonance angiography

The insurer denied the brain magnetic resonance angiography. The denial was upheld.

This is a female with a past medical history of cervical pain, migraines, fibromyalgia, syncope and anxiety.  She had mild migraines until several years ago; not recently an issue.  The patient had previous fainting spells which she felt were due to dehydration. She reported 3 episodes of feeling like she was going to pass out, followed by headache, right-sided numbness/paresthesia, and loss of consciousness.  There was no seizure activity, urinary incontinence or tongue biting.  A magnetic resonance imaging (MRI) of the brain was normal. Given the patient's clinical history and MRI of the brain, further imaging including a MR angiography (MRA) of the head and neck was felt to be medically necessary.

Medical literature indicates head MRA may be indicated if aneurysm or arteriovenous malformation is known or suspected, as indicated by follow-up monitoring for a patient with a history of subarachnoid hemorrhage, aneurysm or arteriovenous malformation, initial evaluation of suspected aneurysm or arteriovenous malformation, or re-evaluation after surgical or endovascular therapy for cerebral artery aneurysm or arteriovenous malformation.  The physician had concern for syncope versus seizure.  An electroencephalogram (EEG) was ordered.  MRI of the brain did not reveal evidence of infarct, mass lesion or hydrocephalus. The patient was to undergo an MRA of the head/neck to exclude the presence of an underlying vascular lesion or dissection.  The patient did not require follow-up monitoring for a history of subarachnoid hemorrhage, a known aneurysm or arteriovenous malformation, and did not require a head MR angiography for initial evaluation of a suspected aneurysm or arteriovenous malformation, such as an acute severe headache.  There was no other indication as to why an MRA of the brain would be appropriate.

The carrier's denial of coverage for the brain magnetic resonance angiography (MRA) is upheld.  The medical necessity is not substantiated.

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


Answer: The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.

Answer: The patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network.

Context:
The patient has cocaine, alcohol, opiate and cannabis dependence and was admitted to an inpatient detox service. Patient endorsed typically using alcohol, heroin and cocaine daily. The reported  last use of cocaine and heroin was the day prior, but had drunk two 24 ounce beers earlier that day. Blood alcohol level was zero and urine was positive for cocaine, opiates and tetrahydrocannabinol (THC). Complained to nursing of hot/cold sweats, tremors, diarrhea, headache, abdominal pain, and joint pain. Initial vital signs included a mildly tachycardic pulse of 105 and a normal blood pressure of 128/72. To the nurse practitioner patient complained of the same symptoms; in addition,  nausea, anxiety, irritability, diarrhea, and teary eyes. The physical exam did document tremors and a flushed appearance. The initial Clinical Institute Withdrawal Assessment (CIWA) score was 16 and Clinical Opiate Withdrawal Scale (COWS) was 15.
The patient reported a psychiatric history of anxiety, depression, and post-traumatic stress disorder (PTSD). Denied current suicidal thoughts and denied current outpatient treatment. Has a history of suicide attempt while intoxicated on alcohol. Patient reported over 100 past treatment episodes and has serious legal and personal consequences from use. Patient was admitted to the detox unit and placed on methadone and Ativan withdrawal protocols. The service of inpatient detoxification treatment was medically necessary The patient has a documented history of chemical dependence on multiple substances (opiates, alcohol, cocaine, and cannabis). Patient has a shelter bed but does not have a sober support network. The CIWA, COWS and physical exam on admission all are consistent with clinically significant withdrawal. Of the substances used, the potential for alcohol withdrawal is the most clinically serious given that alcohol withdrawal can be fatal. Patient does not have a known history of serious withdrawal, but serious withdrawal can manifest at any time in the illness course. The chronicity and amount of  use also places patient at increased risk for withdrawal. The combination of alcohol withdrawal with opiate withdrawal does increase risk of medical complication. An admission LOCADTR  resulted in a recommendation for inpatient services. The HP determination is overturned in whole.

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


Answer: This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.

Answer: The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed.

Context:
This is a patient a past medical history significant for hypertension and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of high blood pressure. Apparently, the patient did not take her blood pressure medications on the day of the presentation to the ED. While in the emergency department, the patient started to have left-sided chest pain that radiated to the left arm. She described the pain as throbbing, non-exertional. The patient also complained of epigastric abdominal pain and nausea. It was associated with sweating and palpitations.
During the hospital stay, the patient was ruled out for acute coronary The health plan's determination of medical necessity is upheld. The patient presented with atypical chest pain. Considering her risk factors, which included hypertension and hyperlipidemia, it was appropriate to rule out acute coronary syndrome and this was ruled out. The patient was seen by the cardiology service and was found to have atypical chest pain. No intervention was needed.
Even though the patient came to the hospital with elevated blood pressure, there was no evidence that she had a hypertensive emergency or any other complications that would require management of the blood pressure in inpatient settings.

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


Answer: The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation.

Answer: The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation.

Answer: the white blood cell count was markedly elevated and he had a relatively high fever.

Context:
The patient presented to the hospital in early 2019. The patient had a history of chronic lymphedema, recurrent lower extremity cellulitis, and scrotal cellulitis. The patient presented complaining of lower extremity edema, warmth, and scrotal pain. The patient's symptoms were worse on the left side. He also reported fever, sore throat, and nausea. The patient denied chest pain, shortness of breath and diarrhea. The plan of care included intravenous (IV) antibiotics, IV fluids, blood cultures, lower extremity ultrasound, ultrasound of the scrotum, and consider iron supplementation.

The health plan's determination is overturned. The inpatient stay is medically necessary. The patient presented with sepsis and cellulitis and had some evidence of hemodynamic instability with tachycardia. He required IV antibiotics and there was concern for toxic shock initially as a possible complication of the patient's presentation. In addition, the white blood cell count was markedly elevated and he had a relatively high fever. The patient was it increased risk of having an adverse outcome because of these factors and it would not have been appropriate to manage at a lower level of care.

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


Answer: The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review.

Context:
The patient was referred from the High Risk OB clinic for admission for glycemic control. The obstetrical history was significant for 1 cesarean section. The patient had history of 2 prior admissions for glycemic control. On presentation, the patient's blood glucose was 61. There were no obstetrical complaints. Fetal heart rate tracing was reassuring. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Based on provided clinical information, the records did not indicate any evidence of hyper/hypoglycemia; fetal heart rate tracing and ultrasound examination were normal; the patient was hemodynamically stable. there was no evidence of ketoacidosis; there was no abnormal bleeding, PPROM (Preterm premature rupture of the membranes) or preterm labor. Insulin regimen (each dose) was increased only by 2 units; the initial and subsequent FS assessments were all normal.

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


Answer: The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.

Answer: Labs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.

Answer: This patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea

Context:
The patient is a previously healthy female, whose family has limited English proficiency, who presented to the emergency department (ED) with fevers, vomiting and diarrhea. Symptoms began approximately 1 month prior with waxing and waning course. There were no associated respiratory symptoms or recent travel. Of note, ED records indicate that this child was still nearly exclusively breast fed.

Labs showed white blood cell (WBC) count of 12 with 44 segs and 43 lymphs, hematocrit (Hct) 32, and platelets (Plt) 562. Sodium (Na) 136, potassium (K) 4.0, chloride (Cl) 105, carbon dioxide (CO2) 15, blood urea nitrogen (BUN) 10, creatinine (Cr) 0.45, and glucose (66). Liver function tests (LFTs) and bilirubin were normal. Initial urinalysis (UA) showed specific gravity (SG) 1.020 and small ketones. The patient received intravenous fluids (IVF) bolus x 2 and intravenous (IV) Zofran. She was admitted to the pediatric ward where she continued to receive IVF and advance diet as tolerated. Her diarrhea and other symptoms improved, and she was able to be discharged home two days later.

The health plan's determination is upheld.

The requested inpatient stay was not medically necessary for this patient.
This patient was hemodynamically stable with mild dehydration secondary to acute gastroenteritis. She received 2 IVF boluses in the ED, but reportedly failed an oral challenge so was admitted to the hospital. Hospital notes indicate continued diarrhea, but do not indicate continued vomiting or other complications. Therefore, based on patient condition her care could have been managed at a lower level of care status.

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


Answer: This is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.

Answer: Diagnosis: Substance Abuse

Answer: Treatment: Inpatient Substance Detoxification

Answer: The insurer denied the Inpatient Substance Detoxification.

Answer: In this case this patient had been using large amounts daily of heroin and crack/cocaine.

Context:
Diagnosis: Substance Abuse

Treatment: Inpatient Substance Detoxification

The insurer denied the Inpatient Substance Detoxification. The denial was reversed.

This is a middle aged male who was admitted for inpatient substance detoxification treatment in late 2018 for heroin and crack/cocaine detoxification. He reportedly was using IV heroin and crack/cocaine use since a young age. He had withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches. He had a history of inpatient substance detoxification and rehabilitation treatments. During hospital admission he was placed on a Methadone taper and was then discharged home.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.

In this case this patient had been using large amounts daily of heroin and crack/cocaine. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use multiple serious substances of abuse daily with a long history despite reports that he had multiple past inpatient substance detoxification and rehabilitation treatments. The patient also required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including severe withdrawal and also was at high risk for overdose so he required this 24 hour inpatient detoxification setting then. Also, he likely would have relapsed again as evidenced by relapsing after past treatments so it was not likely that he could safely and effectively be treated for detoxification in an outpatient setting. It was unlikely that he would remain abstinent while having withdrawal symptoms which he reportedly had as he had reports of withdrawal symptoms including nausea, sweats, yawning, tremors, anxiety, gooseflesh skin, and generalized body aches.

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

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


Answer: Diagnosis: Dental Problems-edentulous spaces

Answer: Treatment: Dental implants placement

Answer: The insurer has denied coverage of dental implants placement.

Answer: This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.

Answer: The insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.

Answer: the patient exhibits edentulous spaces in the areas of #7, 10.

Context:
Diagnosis: Dental Problems-edentulous spaces

Treatment: Dental implants placement

The insurer has denied coverage of dental implants placement. The denial was upheld.

This is a male patient who presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous spaces in the anterior maxilla incisor area with missing teeth #7 and #10.  It appears that the patient completed orthodontic therapy and was wearing a removable prosthesis to replace the missing teeth. The orthodontist discussed treatment plans, which included no additional treatment, fixed or bonded bridges or endosteal implants (with grafts) and implant retained crowns. The patient chose endosteal implants to be placed at the sites after discussion of treatment plans.

The insurer has denied the aforementioned services, stating that in their estimation, endosteal implants are not the only procedure or appropriate treatment. They further state that these services are exclusions from the patients' medical plan coverage, and the insurer will only cover certain dental services under the medical coverage with very specific criteria to be met. Therefore, the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient is appealing the decision.

Upon review of the objective documentation, which primarily consists of the panoramic radiograph, it is evident that the patient exhibits edentulous spaces in the areas of #7, 10. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry includes a fixed bridge of some type. Further, a functional impairment is not documented objectively and none appears to be present; therefore, no actual treatment is required and an option is to do nothing.

Uphold denial of coverage of dental implant placement (21248) and bone graft (21210) as not medically necessary since there is no functional deficit documented. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

Based on the above, the medical necessity for Dental Implant Placement (21248) and Bone Graft (21210) is not substantiated. The insurer's denial is upheld.

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


Answer:
Diagnosis:  Infectious colitis
Treatment:  Inpatient stay

Answer: The patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.

Answer: The patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.

Answer: The patient had infectious colitis

Context:
Diagnosis:  Infectious colitis
Treatment:  Inpatient stay
The acute inpatient admission was not medically necessary.

Summary:
The patient was a female, who presented via ambulance to the ED with the complaints of nausea, vomiting and abdominal pain.

The patient was admitted to start treatment for infectious colitis.  The patient was maintained NPO (nothing by mouth) on intravenous (IV) fluids, IV antibiotics, Zofran and a proton pump inhibitor for acute management of acute infectious colitis.  The patient's tachycardia resolved when her pain was controlled and after getting fluids.  The patient had a repeat set of labs, which showed resolution of the leukocytosis, which lowered the suspicion for a systemic infection cause in this patient.  The patient was taken off antibiotics, and her cultures later returned confirming no bacteremia.  She symptomatically improved, and her vomiting stopped.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care.  The patient had infectious colitis; yet, she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.

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


Answer: This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome.

Context: This patient presented to the emergency department with complaints of three days of intermittent shortness of breath and chest pain. His blood pressure was 119/80 millimeters of mercury (mmHg) with a heart rate of 61 beats/minute. His room air oxygen saturation was 96%. His cardiovascular exam was unremarkable. His electrocardiogram was normal. His serum troponin level was normal. His hemoglobin level was increased at 19.9 grams per deciliter (g/dl). A chest x-ray showed no acute disease. He was treated with nitroglycerin and intravenous hydration and admitted to the hospital to rule out acute coronary syndrome. The health plan's determination is upheld.  Observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. A myocardial perfusion study was performed and was normal. He was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening causes of his chest pain were thought to be likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

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


Answer: The patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review.

Context:
The patient underwent upper and lower jaw surgery and went home the next day. There were no complications noted. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Most patients with this surgery (orthognathic) are treated, observed and discharged the same day or the following day as long as discharge criteria is met. The surgery is accomplished in an operating room (OR) setting and the minimum required to accomplish the surgery. An inpatient setting would not be necessary unless discharge criteria is not met. In the United States, it has been reported that between 46% and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. A study of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006 found that individual variables associated with duration of length of stay (LOS) are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination. In this patient's case, there were no postoperative complications, therefore the patient could have been cared for at a lower level of care.

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


Answer: Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder

Answer: Treatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)

Answer: The insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).

Answer: The patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.

Answer: The insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019.

Context:
Diagnosis:  Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder

Treatment:  Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS)

The insurer has denied Registered Nurse (RN) assessment for recertification of Consumer Directed Personal Assistance Services (CDPAS).  The denial was upheld.

The patient is a male child with diagnoses of ADHD, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Conduct Disorder, and Generalized Anxiety Disorder.  The patient is prescribed Seroquel, Clonidine, and Methylphenidate.  The request was for RN assessment for recertification of CDPAS.  It was reported that the patient could not self-administer medications, needed reminders and redirections to accomplish daily tasks and activities, did not cope well when frustrated or angry, had run away from the classroom, and had a history of throwing objects and pushing students.  It was stated that a personal aide could help manage behaviors.

The insurer denied coverage for RN assessment for recertification of CDPAS.  It was reported that he had this service for 41 1/2 hours from late 2018 to mid-2019.

This reviewer agrees with the decision to deny coverage for RN assessment for recertification of CDPAS.  The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks.  It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves.  Such activities of daily living (ADLs) include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation.

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder does not mention personal care assistance services as a standard for treatment.  It mentions pharmacotherapy, and also behavioral therapy and parent training as standards of treatment.  This service is not indicated for reminders and redirections to accomplish daily tasks and activities; therefore, it is not medically necessary for this child.

As a result, uphold the previous decision and deny coverage for RN assessment for recertification of CDPAS.  The health care plan acted reasonably and with sound medical judgment and in the best interests of the patient.

Based on the above, the medical necessity for the RN assessment for recertification of CDPAS is not substantiated.  The insurer's denial is upheld.

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


Answer: The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing.

Context:
The patient  was admitted to the hospital and discharged the following day. The patient was admitted for diagnostic evaluation of episodes of jerking of the  body which had started 1 week prior to admission. The movements were initially left sided but had been bilateral for the previous 2 days. They decreased with activity and did not occur during sleep. There was no associated loss of consciousness, urinary incontinence, tongue biting or post-ictal confusion. The patient dropped items that they were  holding during an episode.The patient was admitted to the hospital for a diagnostic workup which included an magnetic resonance imaging (MRI) brain, video electroencephalogram (EEG) telemetry, lumbar puncture, blood and urine testing. The health plans determination of medical necessity is  overturned in whole. the requested health service/treatment of the inpatient hospital stay was medically necessary for this patient.
 The inpatient stay was medically necessary, and met the criteria for Inpatient Admission for Neurology under the Milliman Care Guidelines  Health Inpatient & Surgical Care,  which states:
"Hospital admission is needed for appropriate care of the patient because of 1 or more of the following: New onset severe neurologic finding requiring inpatient care indicated by 1 or more of the following: Involuntary movements. The differential diagnosis of the onset of involuntary movements , and included seizures, movement disorder which can be due to underlying infectious or autoimmune illness, or tics.,The  inpatient admission for video EEG telemetry and diagnostic workup including lumbar puncture with sedation was medically necessary in order to correctly diagnose the paroxysmal events that the patient was exhibiting. and prevent the patient  from being inappropriately treated.

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


Answer:
Diagnosis:  Abnormal pap smear
Treatment:  Inpatient admission

Answer: The patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea.

Context:
Diagnosis:  Abnormal pap smear
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

An outpatient observation bed is an alternate level of healthcare compromising of short stay encounters for patients who require close nursing observation or medical management.  It is an area where the patient is observed and assessed following surgery to determine a need to be admitted to the hospital as an inpatient.
The patient in question was taken to the operating room and underwent an uncomplicated fractional dilation and curettage with hysteroscopy procedure for an abnormal pap smear of atypical glandular cells of undetermined significance.  After surgery she was not ready for discharge same day.  She required observation and nursing care to assist with her ambulation and medical management of her pain and nausea.   This could have been done in an observation status.  By post-operative day #1 the patient was ready for discharge, requiring less than a 24 hour stay.  Therefore, the patient did not require an acute inpatient stay, as the same care could have been provided under an observation status.

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


Answer: The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain.

Context: The patient with no significant past medical history who presented to the emergency department with complaints of nausea, vomiting, and abdominal discomfort that had been going on for 2-3 days. At the time of the initial evaluation, the patient denied fever, chills. The patient was evaluated by general surgery and was found to have no surgical cause of pain. the health plans determination of medical necessity is upheld in whole. The patient's clinical symptoms, including mild dehydration and mild electrolyte derangements, could have been handled at a lower level of care. The lower level of care was justified to ensure clinical stability and to ensure reliable oral intake. The inpatient level of care was not medically necessary for this patient, based on the severity of the patient's condition and the complexity of services.

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


Answer: This is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.

Answer: The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.

Answer: He was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home.

Context:
The patient is a male who presented with vomiting and diarrhea.  He was well until the week prior to admission when he was traveling to New York after a visit to Peru.  At that time he began to have multiple episodes of emesis.  The emesis continued for 2 days before subsiding, and shortly after he developed diarrhea.  He described an average of 8 episodes of watery, non-bloody diarrhea with mucus every day.  This was accompanied by diffuse abdominal pain.
He was admitted for treatment of gastroenteritis with moderate dehydration.  He was given intravenous fluids as well as Zofran when necessary and bowel rest.  He continued to have diarrhea after admission and was started on a clear liquid diet.  His stool polymerase chain reaction (PCR) was found to be positive for rotavirus.  With hydration during the hospitalization, his electrolyte abnormalities resolved, and he was able to advance his diet.  His diarrhea had decreased, and he was stable for discharge to home.

The health plan's determination is overturned.

This is a patient who presented with severe diarrhea after traveling out of the country. By the time of presentation he was having up to 12 episodes of diarrhea per day.  He had decreased urine output and had developed dehydration.  In the emergency department he was found to have orthostatic hypotension and abnormal laboratory values.  He required prompt initiation of intravenous hydration, as well as antiemetics as needed and close monitoring in an inpatient setting.
The decision-making at the time of admission was consistent with his young age, the presence of severe diarrhea in the setting of travel to different country, the presence of symptomatic dehydration, and the need for prompt initiation of treatment with close monitoring for potential deterioration of clinical status.

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


Answer: The patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.

Answer: Diagnosis: ESRD, hyperphosphatemia, hypercalcemia

Answer: Treatment: Medication- Renvela

Answer: The insurer denied coverage for Renvela.

Context:
Diagnosis: ESRD, hyperphosphatemia, hypercalcemia

Treatment: Medication- Renvela

The insurer denied coverage for Renvela. The denial was upheld.

The patient has a history of end stage renal disease and hyperphosphatemia; also noted to have hypercalcemia and is not a candidate for PhosLo. Treating provider is requesting Renvela for her condition.

Renvela is not considered medically necessary for this patient. There is no current evidence-based literature that Renvela is safer or more effective than available preferred medications (Sevelamer carbonate, Fosrenol and Velphoro).  Based on documentation submitted, the patient has not tried and failed the preferred medications.

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


Answer: This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.

Answer: She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology.

Context:
This is a patient with a past medical history of hyperlipidemia, osteoporosis, vertigo, who presented to the emergency room (ER) with vertigo, headache, nausea and vomiting. She had these symptoms on and off for two months, but she had worsening vertigo pulling to her left side, and a headache which localized to the right frontal area, for one hour prior to presentation. She had a National Institute of Health Stroke Scale (NIHSS) of 0 on admission.
The health plan's determination of medical necessity is upheld. She  was hemodynamically stable, without a major electrolyte abnormality, cardiac or respiratory issues, and without focal weakness, sensory changes, altered mental status, or slurred speech. The initial workup included a CT scan of the head and a CT angiogram of the head and neck was unrevealing. The neurologist's initial assessment was of a peripheral cause of the patient's symptoms as opposed to a central etiology.
According to an American Family Physician (AFP) review article on dizziness: "Evaluation focuses on determining whether the etiology is peripheral or central. Peripheral etiologies are usually benign. Central etiologies often require urgent treatment."

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


Answer: This is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.

Answer: Diagnosis: Colitis and Campylobacter Infection

Answer: Treatment: Inpatient Admission

Answer: The insurer denied the Inpatient Admission.

Context:
Diagnosis: Colitis and Campylobacter Infection

Treatment: Inpatient Admission

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

This is a young female patient who presented to the Emergency Department with complaints of worsening abdominal pain following a recent diagnosis and treatment for a Campylobacter infection. She reports a benign medical history. Vital signs on presentation included: a temperature of 37C, a blood pressure of 108/74, a pulse of 74, a respiratory rate of 18, and an oxygen saturation of 99% on room air.  The patient was given intravenous (IV) fluids and started on intravenous antibiotics (Azithromycin). She was kept nothing by mouth (NPO). A Computerized Tomography (CT) scan of the abdomen showed changes consistent with colitis. Gastroenterology consulted and recommended slowly advancing the diet as tolerated. Infectious Diseases was also consulted and recommended continuation of antibiotics. She underwent a colonoscopy. The patient remained afebrile and hemodynamically stable and was discharged to continue antibiotics as an outpatient.
A Campylobacter infection is an important cause of acute diarrhea and may produce systemic illness, as well as other complications. Based on patient's documented failure of outpatient management, the need for IV fluids, maintaining NPO status, IV antibiotics, and a diagnostic procedure (colonoscopy), the hospital admission was medically necessary.

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

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


Answer:
Diagnosis: Obesity
Treatment: Saxenda

Context:
Diagnosis: Obesity
Treatment: Saxenda
The treatment with Saxenda is medically necessary.

Saxenda is a GLP1 (glucagon-like peptide-1) agonist that is used in the treatment of obesity [1-3]. The FDA label is below [4].

-INDICATIONS AND USAGE
Saxenda is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of
- 30 kg/m2 or greater (obese) (1) or
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g. hypertension, type 2 diabetes mellitus, or dyslipidemia) (1).
Limitations of Use:
- Saxenda is not indicated for the treatment of type 2 diabetes (1).
- Saxenda should not be used in combination with any other GLP-1 receptor agonist (1).
- Saxenda should not be used with insulin (1, 5.4).
- The effects of Saxenda on cardiovascular morbidity and mortality have not been established (1).
- The safety and efficacy of coadministration with other products for weight loss have not been established (1).
- Saxenda has not been studied in patients with a history of pancreatitis (1, 5.2).

The patient meets accepted criteria for use of the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan's requirement of documentation of current and prior enrollment in a comprehensive weight management program like Weight Watchers or Curves Complete is not consistent with the FDA-approved indications for Saxenda.

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


Answer:
Diagnosis: Chest pain
Treatment: Inpatient admission

Answer: The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended.

Context:
Diagnosis: Chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

The patient presented with new onset chest pain, suggestive of unstable angina. The ECG was abnormal, consistent with ischemic changes. The presentation was in the setting of hypertensive urgency. A stress test was abnormal as well, consistent with ischemia. There was a high index of suspicion for an ACS, and a cardiac catheterization was recommended. Given the presentation, uncontrolled hypertension, as well as clinical suspicion for an acute coronary syndrome/unstable angina, he would not be an appropriate candidate for an ED chest pain observation unit.  It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.

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


Answer: The patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic.

Answer: Diagnosis: Rectal bleeding

Answer: Treatment: Inpatient admission, monitoring

Answer: The insurer denied the inpatient hospital admission.

Answer: This patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding.

Context:
Diagnosis: Rectal bleeding

Treatment: Inpatient admission, monitoring

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

The patient presented with rectal bleeding. The patient initially had dizziness, but at the time of admission the dizziness had resolved. The patient was afebrile and the vital signs were stable. The abdominal exam was benign. A rectal exam did not reveal any bleeding. The hemoglobin was 13.8. The bleeding was felt to be due to hemorrhoids. The patient was treated for constipation and referred to Gastrointestinal (GI) clinic.

Clinical indications for admission for lower GI bleeding (M-182) include having ongoing active bleeding, failure to control bleeding after a colonoscopy, coagulopathy, intestinal obstruction, and severe thrombocytopenia. The patient did not have these conditions. The patient also did not have hemodynamic instability, severe anemia, severe pain or an inability to maintain oral hydration.

This patient had minor self-limited bleeding. The patient remained hemodynamically stable and there was no evidence of active ongoing bleeding. The patient did not meet MCG criteria for admission for lower GI bleeding.

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

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


Answer: This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.

Answer: There was a new infiltrate on X-Ray.

Answer: This patient has had transfusion of PRBCs in the past.

Context: This is a child with known sickle cell disease HbSS, who presented with fever and upper respiratory infection (URI) symptoms for 3 days along with loose stools for 4 days. The patient was with a poor appetite x 1 week. Temperature maximum was 101. A chest X-ray showed questionable pneumonia. The patient was given intravenous (IV) Ceftriaxone and admitted to the hospital. The patient had multiple admissions since birth. The patient received packed red blood cells (PRBC) in the past. On this admission the white blood cell count (WBC) was 15,100 and hemoglobin (Hgb) was low at 6.4. The liver function tests (LFTs) were normal. The respiratory syncytial virus (RSV) and flu tests were negative. Blood cultures were done. On physical exam the patient was in no acute distress. The lips were mildly dry. The patient had harsh breath sounds. The Abdomen revealed a liver 2cm below the right costal margin. The registered nurse (RN) documented the child to have dry cracked lips with furred tongue and also looking weak. After admission the spleen was palpable at the left costal margin with inspiration. His WBC increased to 23.3 later on the day of admission. The patient was followed and intravenous fluids (IVF) were administered. The Hgb went up to 7.0 during admission.  The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Inpatient Hospital Admission is medically necessary for this patient. There was a new infiltrate on X-Ray. This would be indicative of acute chest syndrome (ACS). "Clinically, ACS is defined by a new pulmonary infiltrate on chest radiograph in addition to one or more of the following: fever, tachypnea, dyspnea, hypoxia, and chest pain. ACS is a common and potentially lethal complication of sickle cell disease." This patient has had transfusion of PRBCs in the past. The low hemoglobin coupled with diarrhea, poor (PO) intake and physical signs of dehydration would also predispose the patient to crisis due to  sickle cell. IV hydration, monitoring  Intake's and Output's, (PO) intake, stool output as well as fever curve and O2 saturation would be proper care for this patient.

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


Answer:
Diagnosis:  Issue conceiving
Treatment:  IUI

Answer: This patient was able to conceive following donor insemination but had a miscarriage.

Context:
Diagnosis:  Issue conceiving
Treatment:  IUI
The proposed treatment with IUI was not medically necessary.

According to the American Society for Reproductive Medicine (ASRM), infertility is a disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination.  Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six months for women over age 35 years.

This patient was able to conceive following donor insemination but had a miscarriage.  In other words, she did not fail to conceive after six therapeutic donor inseminations, and, therefore, she does not have a diagnosis of infertility.  In the absence of such a diagnosis, treatment for infertility including the intrauterine insemination performed is not medically necessary.

The request is not medically necessary, since this patient did not have an illness, injury or disease:  She has inability to conceive due to non-exposure to sperm and due to aging a normal, natural physiological process.  The standard of care is for this patient to fail six inseminations (i.e. fail to get pregnant) before she is considered infertile and eligible for coverage of infertility services.

In summary, this patient's inability to conceive is due to natural aging and non-exposure to sperm.  She does not have a diagnosis of infertility, and the requested coverage for IUI was not medically necessary.

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


Answer: The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation.

Answer: The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay.

Context:
The patient was admitted to the hospital. The patient has a past medical history of Parkinson's disease and hypertension and presented after a syncopal episode. The patient was noted to be unresponsive and cardiopulmonary resuscitation (CPR) was initiated. Vital signs showed a blood pressure of 185/71, pulse 97, respiratory rate 18 and oxygen saturation 96%. Labs showed a white blood cell count of 7.3, hemoglobin 9.2, platelets 158, sodium 140, potassium 3.6, creatinine 0.8 and a glucose of 113. An electrocardiogram (EKG) showed sinus rhythm with frequent PVCs (premature ventricular contractions). A computed tomography (CT) of the brain showed no acute intracranial abnormalities. The patient was admitted for further management and evaluation.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented after a syncopal episode. Her EKG showed sinus rhythm. The head CT was negative for acute intracranial abnormalities. The patient was hemodynamically stable. An ultrasound (US) carotid showed no stenosis. No sustained ectopic foci were noted on Holter. Amantadine and Donepezil were discontinued per neurology recommendation. The patient was started on Ropinirole and Sinemet. She was also evaluated by physical therapy. No complicating events occurred during the stay. This patient's care could be provided at a lower level as there was no hemodynamic instability, pulmonary embolism, arterial dissection, acute congestive heart failure exacerbation, cardiac ischemia, atrial fibrillation or need for continuous intravenous infusion.

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


Answer: The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week.

Answer: The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services.

Context:
The patient is a male with a significant past medical history for diabetes mellitus, hypertension, chronic kidney disease, gastroesophageal reflux disease and nephrolithiasis. The subject under review is for the medical necessity of increase in personal-care service hours from 17 hours a week to 40 hours a week. The patient has currently been approved for 17 hours a week. The patient requests additional services to 40 hours a week. The health plan's determination is overturned, in part. The requested health service/treatment of Consumer directed personal cares assistance services increase from 17 to 40 hours per week is not medically necessary for this patient. However, an increase to 20 hours a week is medically necessary.
The patient's son stated that the patient needs assistance with feeding, medication, and walking. He reports the current hours are not enough, and are not adequate for bathing, dressing, toileting, and housekeeping related services. Per the Uniform Assessment System - New York Comprehensive Community Assessment Report, the patient is independent with eating, ambulates in his own home with an assistive device, and is continent of bowel and bladder. The Uniform Assessment System - New York Comprehensive Community Assessment Report recommended a total of 19 hours a week for personal care services. Based upon review of the records provided along with the documents provided in regards to nursing and aid hours, the patient would need additional hours to support basic functions such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The recommended increase in the personal-care hours from 17 hours a week to 20 hours a week should be sufficient to maintain activities that were noted to be medically necessary according to the documentation provided. There is no medical need for additional hours other than 20 hours a week.

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


Answer: Diagnosis: Chest pain, shortness of breath

Answer: Treatment: Inpatient admission, diagnostic testing, medication, monitoring

Answer: The insurer denied the inpatient hospital admission.

Answer: The patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air.

Answer: The patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix.

Answer: In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology.

Context:
Diagnosis: Chest pain, shortness of breath

Treatment: Inpatient admission, diagnostic testing, medication, monitoring

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

The patient presented to the Emergency Department (ED) with acute onset of chest pressure and diaphoresis. The patient reported right lower extremity cramping and left lower extremity swelling. The patient has a productive cough with green sputum and mild rhinorrhea. The patient has a past medical history of Marfan syndrome, Diabetes Mellitus type II, previous heart attack, status post mechanical aortic valve replacement (AVR), status post left heart catheterization with percutaneous coronary intervention (PCI) and recent admission due to melena and hematochezia. The patient had symptoms of an upper respiratory infection (URI), shortness of breath with intermittent paroxysmal nocturnal dyspnea (PND). The patient states that for the past few days The patient has had sub sternal pressure like chest pain which is similar to when The patient was diagnosed with non-ST elevated myocardial infarction (NSTEMI). The patient states that the pressure radiates to his back but only when The patient is laying down and reports that this is been ongoing for the past month. His vital signs include temperature 36.6 C, heart rate 60, blood pressure 169/80, respirations 18 and oxygen saturation 99% on room air.

The patient's atypical chest pressure/congestion resolved after receiving intravenous (IV) Lasix. The symptoms were not typical for acute coronary syndrome (ACS). In the hospital The patient did not have any recurrence of significant chest pain and his workup revealed normal troponins and a BNP that was only slightly elevated. His Electrocardiogram (EKG) showed no change from previous recordings and no evidence of acute myocardial injury or ischemia. An echocardiogram and a Computer Tomogram (CT) of the chest did not reveal any significant pathology.

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

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


Answer:
Diagnosis: Shortness of breath and Chest Pain
Treatment: Inpatient admission

Answer: This is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.

Answer: Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition.

Context:
Diagnosis: Shortness of breath and Chest Pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This is a female with a history of pulmonary embolism who presented to the ER for further evaluation/management of dyspnea and chest pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received therapeutic anticoagulation, supportive care with IV fluids and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition.

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the inpatient admission was not medically necessary.

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