Answer:
Diagnosis: Gynecomastia.
Treatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).

Answer: This patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.

Answer: The patient has gynecomastia

Context:
Diagnosis: Gynecomastia.
Treatment: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The insurer denied: Breast Reduction and Suction Assisted Lipectomy, Trunk (Removal of Extra Breast Tissue).
The denial is upheld.

This patient is a young adult male who presents with complaints of fullness behind both nipples since adolescence. The patient reports developing breast tissue just behind the nipples on both sides which caused projection. He has lost weight and has begun to work out in the gym frequently with a continued projection of the nipple. He reports that when he is cold and he has hardening of the nipples he has a normal profile. He would like to surgically correct the shape and fullness of his nipple. The patient denies taking prescription medications. He denies taking illicit drugs including marijuana. He denies testicular masses. Mastectomies and liposuction are planned.

The proposed treatment is not medically necessary.
The mastectomies are cosmetic. The patient has gynecomastia, but the records do not document any health or functional problems caused by the enlarged breasts. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for a breast malignancy and there are no diagnostic studies provided. The records do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts.

Gynecomastia is a benign condition that does not cause health or functional problems.  According to a review article from the Mayo Clinic, "Overall, gynecomastia is a benign condition and is usually self-limited. Over time, fibrotic tissue replaces the symptomatic proliferation of glandular tissue and tenderness resolves. If the appropriate work-up does not reveal considerable underlying pathology, reassurance and periodic follow-up are recommended...Patients with gynecomastia have a favorable prognosis. These patients present with 2 main concerns: ruling out breast cancer and cosmetic correction. The first concern is adequately addressed by following the appropriate diagnostic evaluation. Breast cancer is rare in males, representing less than 1% of all cases of breast cancer; only 1% of mammograms in men reveal breast cancer.  Therefore, the decision to treat and the choice of treatment should be based on the degree to which this condition has affected the quality of life and mental health of patients and on their desire for cosmetic correction."

The records do not provide any evidence of concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance, and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefits from the surgery, but his physiologic health will not be improved.

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


Answer:
Diagnosis: Facial cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission

Answer:
This is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation.

Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.

Patient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient.

According to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required.

Context:
Diagnosis: Facial cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation.

Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.

Patient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient.

According to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required. Based on above findings, patient did not meet criteria for acute inpatient admission. Patient met criteria for observation level of management.

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

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

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


Answer:
Diagnosis: Type 2 diabetes mellitus.
Treatment: Afrezza
The insurer denied Afrezza.

Answer: This is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.

Answer: The patient is unable to self-inject to due needle phobia.

Context:
Diagnosis: Type 2 diabetes mellitus.
Treatment: Afrezza
The insurer denied Afrezza.
The health plan's determination is overturned.

This is a male diagnosed with Type 2 diabetes mellitus with hyperglycemia. This request is for Afreeza. As reported, he has a severe phobia of needles making it so that he has been unable to give rapid-acting insulin injections. He has previously prescribed Novolog for treatment but failed due to his inability to inject due to his phobia.

The formulary alternative will be ineffective as the patient cannot self-inject insulin due to needle phobia.
Afrezza is FDA (Food and Drug Administration) approved for the treatment of diabetes. It has been shown to be beneficial in patients with diabetes. Studies have demonstrated the safety and efficacy of the medication and treatment of diabetes. There are no studies showing the superiority of Afrezza over injectable insulin. The patient is unable to self-inject to due needle phobia. A formulary exception is indicated.

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


Answer:
Diagnosis: Type 2 Diabetes
Treatment: Freestyle Libre supplies
The insurer denied Freestyle Libre supplies.

Answer: This is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity.

Context:
Diagnosis: Type 2 Diabetes
Treatment: Freestyle Libre supplies
The insurer denied Freestyle Libre supplies.
The determination is upheld.

This is a male patient with type 2 diabetes with neuropathy treated with metformin and Ozempic. The patient's A1C is 5.8 percent (%). Freestyle Libre supplies were denied by the health plan and are under review for medical necessity.

The requested Freestyle Libre supplies are not medically necessary for this patient. The requested service is for the management of type 2 diabetes for a patient who is not on insulin therapy. Long-term continuous glucose monitoring has been shown to be safe and effective for people with type 2 diabetes on multiple daily insulin injections and basal insulin therapy. The safety and efficacy of continuous glucose monitoring has not been sufficiently studied in people with type 2 diabetes in the absence of insulin therapy to determine safety and efficacy in this clinical situation. The use of continuous glucose monitoring in this clinical situation is not supported by the Endocrine Society guidelines [1] or the American Diabetes Association clinical guidelines [2]. Therefore, the requested Freestyle Libre supplies are not medically necessary for this patient.

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


Answer:
Diagnosis: Osteomyelitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

Answer:
Asked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior
wall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically
for type II myocardial infarction.  He was ultimately diagnosed with infection due to
osteomyelitis of the distal extremity and was discharged on antibiotic therapy.

Answer: this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis

Answer: This patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high.

Context:
Diagnosis: Osteomyelitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

Asked to review the case of an adult male that presented to the hospital with fever of 101.7 degrees F and symptoms of nausea and vomiting. Past medical history was significant for metastatic pancreatic cancer on chemotherapy, diabetes mellitus, hypertension, coronary artery disease status post right coronary artery (RCA) stent, and pulmonary embolus.  On arrival to the hospital blood pressure was 98/51 and pulse was 78. Physical examination was significant for poor distal pulses on lower extremities and  a second right toe amputation. Electrocardiogram demonstrated sinus rhythm with Q waves inferiorly and nonspecific T wave changes.  Serum blood testing demonstrated several abnormalities: White blood cells (WBC) 18,000 with bandemia, lactate of 2.0, troponin of 240, and B type natriuretic peptide of 3498.  Chest X ray revealed a right lower lung infiltrate. The patient was treated with intravenous antibiotics and admitted to the hospital for ischemia work up and sepsis work up.  Echocardiogram revealed an left ventricular ejection fraction (LVEF) of 55% with mild inferior
wall hypokinesis and with moderate mitral regurgitation.  The patient was treated medically
for type II myocardial infarction.  He was ultimately diagnosed with infection due to
osteomyelitis of the distal extremity and was discharged on antibiotic therapy.

This patient presented with fever, nausea and vomiting and an elevated serum troponin level.  His pretest probability of coronary artery disease was high.(Reference 1)  Utilizing the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) he was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In addition to the issue of an acute coronary syndrome, this patient had multiple medical problems including metastatic pancreatic cancer and possible sepsis.  The patient was ultimately diagnosed with osteomyelitis that likely contributed to a type 2 myocardial infarction. (Reference 4).

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for full hospital admission is substantiated.

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


Answer:
Diagnosis:  Dental Issues.
Treatment:  Braces and Monthly Visits.

The insurer denied the braces and monthly visits.

Answer: The patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary.

Context:
Diagnosis:  Dental Issues.
Treatment:  Braces and Monthly Visits.

The insurer denied the braces and monthly visits.  The health plan's determination is upheld.

The patient is a male with a Class I malocclusion, moderate maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The subject to be determined is if the requested health service/treatment of braces and monthly visits are medically necessary.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The treatment for braces and monthly visits is not medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5 millimeter (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces are not medically necessary.

The health plan's determination is upheld in whole.

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


Answer:
Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder
Treatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week
The insurer denied the CDPAS for a total of 168 hours/week.

Answer: This elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom.

Answer: This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours.

Context:
Diagnosis: Cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder
Treatment: Consumer Directed Personal Aide Services (CDPAS) for A total of 168 hours/week
The insurer denied the CDPAS for a total of 168 hours/week.
The denial is overturned.

This elderly female has medical conditions that include cervicalgia, insomnia, low back pain, fibromyalgia, major depressive disorder, anxiety, osteoarthritis, diabetes, hypothyroidism, anemia, abnormal gait, and urinary incontinence. Denial of Consumer Directed Personal Aide Services (CDPAS) for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The patient needs assistance with ADLs (activities of daily living). She is frequently incontinent and cannot change or dress independently. A statement from her provider notes her condition is worsening. She has a history of multiple falls. She is unable to use her left arm after a shoulder injury. She uses the commode every 2-4 hours and cannot transfer without assistance. She needs to be cleaned and changed frequently during night due to incontinence. A statement from her children notes she lives alone. She has difficulty walking and cannot get to the bathroom or out of chair or bed when her aide leaves. She wakes up 5-6 times per night and needs assistance with going to the bathroom.

The proposed treatment is medically necessary.

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. Denial of CDPAS for a total of 168 hours/week is being appealed. The health plan approved 70 hours/week. The statement provided indicates that the patient's condition is deteriorating. She needs assistance with ADLs. She has urinary incontinence and requires assistance with transferring and toileting every 2-4 hours. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS for 70 hours/week is insufficient to support her continuous needs. The proposed CDPAS for a total of 168 hours/week, split shift is medically necessary.

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


Answer:
Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission

Answer: The patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for "septal defect repair", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.

Answer: This patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%.

Context:
Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for "septal defect repair", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.

The proposed treatment was medically necessary.

This patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%. Hospitalization for diagnostic testing and treatment is clearly needed given the increased morbidity and mortality associated with both supraventricular and ventricular arrhythmias in this patient population. (Reference 1, 2)
This patient required additional work up to assess the nature of his arrhythmia and potentially eliminate recurrent arrhythmia that might result in additional future implantable cardioverter defibrillator therapies. The patent appropriately underwent diagnostic electrophysiologic testing and was ultimately treated with escalating doses of beta blocker therapy. This patient's comorbid conditions and presentation required a higher level of care. In conclusion, inpatient hospital admission was medically necessary.

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


Answer:
Diagnosis: Pressure ulcers

Treatment: Topical Oxygen Wound Therapy (TOWT)

The insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)

Answer: According to the surgeon's note : "This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers."  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately.

Context:
Diagnosis: Pressure ulcers

Treatment: Topical Oxygen Wound Therapy (TOWT)

The insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)

The denial is upheld

According to the surgeon's note : "This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers."  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately.  Multiple studies have been published showing efficacy for Topical Oxygen Wound Therapy (TOWT) for the management of diabetic ulcers.  There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

Topical Oxygen Wound Therapy (TOWT) is not considered medically necessary for this patient. There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

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

The medical necessity for Topical Oxygen Wound Therapy (TOWT) is not substantiated.

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


Answer:
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen
The insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.

Answer: The patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).

Answer: The patient's A1C was 6.0%. He is being treated with metformin.

Answer: This request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea.

Context:
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen
The insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.
The denial is upheld.

The patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).

The health plan should not cover the formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea. The documentation does not indicate that the patient has tried and failed the remaining alternatives or that the patient has a contraindication to these alternatives. The patient's A1C was 6.0%. He is being treated with metformin. The patient does not have a prior documented A1C that was elevated to document a need for additional glucose lowering medication. The American Diabetes Association clinical guidelines do not support the use of Mounjaro in this clinical situation. Mounjaro has risks, including nausea and vomiting. Therefore, no, the health plan should not cover the formulary exception for Mounjaro.

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


Answer:
Diagnosis: Heart Failure
Treatment: Entresto
The insurer denied Entresto.

Answer: This is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue.

Context:
Diagnosis: Heart Failure
Treatment: Entresto
The insurer denied Entresto.
The determination is overturned.

This is a male patient with a history of atrial fibrillation and nonischemic cardiomyopathy. An echocardiogram showed a dilated left ventricle with global hypokinesis and a left ventricular ejection fraction of 25-30 percent (%). There was severe mitral regurgitation. Per the physician's appeal letter the patient has New York Heart Association Functional Class II heart failure. The medical necessity for Entresto is at issue.

Based on the information provided, Entresto is medically necessary.

Entresto (sacubitril/valsartan) is a relatively new, first-in-class medication that combines an angiotensin receptor blocker with a neprilysin inhibitor. In the pivotal trial of Entresto, 4187 patients with New York Heart Association (NYHA) Class II-IV heart failure and reduced left ventricular ejection fractions (less than or equal to 40%) were randomly assigned to receive either Entresto or standard therapy with enalapril, an angiotensin converting enzyme (ACE) inhibitor. During a median follow-up time of 27 months, the combined endpoint of death from cardiovascular cause or heart failure hospitalization occurred in 21.8% of the Entresto group versus 26.5% of the enalapril group; this difference was highly significant and in favor of the Entresto group. The American College of Cardiology (ACC) / American Heart Association (AHA) / Heart Failure Society of America (HFSA) guidelines for heart failure have given its use a Class I recommendation in this patient population.

Per the policy provided Entresto is medically necessary when:
1.	The individual is at least 18 years of age; (MET)
2.	The individual is using the drug for NYHA class II, III or IV symptoms: (MET)
3.	AND
4.	The individual has a left ventricular ejection fraction of 57% or less. (MET)

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


Answer:
Diagnosis: Alzheimer's dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.

Answer: This elderly female patient has conditions including Alzheimer's dementia. The denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. Uniform Assessment System evaluation completed 5 months ago showed severely impaired cognition and functional status: total dependence to maximal assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. There is no significant change compared to Uniform Assessment System evaluation completed 16 months ago. The patient's daughter reports that the patient has deteriorated since being diagnosed with COVID (coronavirus disease). A letter from the patient's physician notes the patient has rapidly deteriorating cognitive and physical health and functioning. She is confined to the bed and wheelchair. She has progressive dementia. She requires assistance multiple times per day with diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs).

Answer: This patient has chronic conditions that include Alzheimer's dementia. Denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week for 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. The health plan denied the additional hours based on the Uniform Assessment System (UAS) evaluation and noted that hours could be adjusted to meet the patient's needs. Uniform Assessment System evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 16 months ago, the patient required maximal assistance to total dependence with all activities of daily living. The appeal statements note that the patient's cognitive and physical functioning are deteriorating. She is confined to the bed and wheelchair. The information provided shows that this patient has significant limitations in functioning.

Context:
Diagnosis: Alzheimer's dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.
The denial is partially overturned.

This elderly female patient has conditions including Alzheimer's dementia. The denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. Uniform Assessment System evaluation completed 5 months ago showed severely impaired cognition and functional status: total dependence to maximal assistance with all activities of daily living (ADLs). She has bowel and bladder incontinence. There is no significant change compared to Uniform Assessment System evaluation completed 16 months ago. The patient's daughter reports that the patient has deteriorated since being diagnosed with COVID (coronavirus disease). A letter from the patient's physician notes the patient has rapidly deteriorating cognitive and physical health and functioning. She is confined to the bed and wheelchair. She has progressive dementia. She requires assistance multiple times per day with diaper changes. She requires continuous supervision and assistance with activities of daily living (ADLs).

An increase in consumer directed personal assistance program (CDPAP) to 24 hours per day, 7 days per week, live in, is medically necessary for this patient. However, an increase in consumer directed personal assistance program (CDPAP) and:12 hours per day, 7 day(s) per week; 12 hours per day, 7 day(s) per week (split shift) - for a total of 168 hours per week is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. This patient has chronic conditions that include Alzheimer's dementia. Denial of an increase in consumer directed personal assistance program (CDPAP): 12 hours per day - 7 days per week for 12 hours per day - 7 day(s) per week (split shift) - for a total of 168 hours per week is being appealed. The health plan approved 9.5 hours per day for a total of 66.5 hours per week. The health plan denied the additional hours based on the Uniform Assessment System (UAS) evaluation and noted that hours could be adjusted to meet the patient's needs. Uniform Assessment System evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed 16 months ago, the patient required maximal assistance to total dependence with all activities of daily living. The appeal statements note that the patient's cognitive and physical functioning are deteriorating. She is confined to the bed and wheelchair. The information provided shows that this patient has significant limitations in functioning. The approved consumer directed personal assistance program (CDPAP) at 66.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The information does not support that the patient has continuous needs that will not allow an aide 5 hours of sleep. The proposed consumer directed personal assistance program (CDPAP) 12 hours per day - 7 days per week and 12 hours per day - 7 days per week, split shift, is not medically necessary. However, an increase consumer directed personal assistance program to 24 hours per day, 7 days per week, live in, is medically necessary for this patient.

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


Answer:
Diagnosis: Knee pain.
Treatment: Inpatient admission.
The health plan denied inpatient admission.

Answer:
The patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.

The patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.

Answer: The anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure).

Answer: The patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2.

Answer: The patient was also found to have continued pain to require PCA (patient-controlled analgesia).

Answer: BMI (body mass index) 45.

Context:
Diagnosis: Knee pain.
Treatment: Inpatient admission.
The health plan denied inpatient admission.
The denial is overturned.

The patient is an adult male with knee pain. He has a history of severe morbid obesity, hypertension, and non-ischemic cardiomyopathy. He had undergone a left total knee replacement last year complicated by pain and decreased motion. He had undergone MUA (manipulation under anesthesia) x 2.

The patient was admitted to the hospital and discharged two days later. His surgery was arthrotomy, synovectomy and arthrolysis. He required PCA (patient-controlled analgesia), CVAC (Central Venous Access Catheter) and monitoring after the procedure.

The records show a complex and unique clinical condition to warrant the services provided. The important findings to substantiate inpatient admission are as follows:
BMI (body mass index) 45. This is an outlier to ambulatory arthroplasty. The patient would be at extremely high risk for complications.
The anesthesia time was nearly 5 hours. The patient has COPD (chronic obstructive pulmonary disease) with reported need for CPAP (continuous positive airway pressure). There would be an increased risk of pulmonary problems.
The patient had a drain in place with continued output. A special VAC (vacuum-assisted closure) drain was placed. It was not removed until POD (post-operative day) #2. A patient would not be able to be discharged with active drainage.
The patient was also found to have continued pain to require PCA (patient-controlled analgesia).

Based upon the described clinical condition, the inpatient admission and length of stay was warranted and medically necessary.

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


Answer:
Diagnosis: Idiopathic short stature
Treatment: Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN (subcutaneous solution pen injector)
The insurer denied coverage for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN

Answer:
This is a teenager diagnosed with idiopathic short stature (ISS). This request is for Norditropin. His height velocity is reported to be 6.7 centimeters per year (cm/yr). He is at tanner 3. His insulin like growth factor 1 (IGF1) was 297 and insulin like growth factor binding protein 3 (IGFBP3) was 3.62.

His weight was 41.50 kilograms.
His height 150.5 cm (-2.24 standard deviation (SDS))
His mother's height is 160.02 cm and father's height is 162.56 cm and mid parental height is 167.8 cm (-1.26 SDS)
His predicted adult height is 171 cm, -0.81 SD.

Context:
Diagnosis: Idiopathic short stature
Treatment: Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN (subcutaneous solution pen injector)
The insurer denied coverage for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN
The denial is upheld

This is a teenager diagnosed with idiopathic short stature (ISS). This request is for Norditropin. His height velocity is reported to be 6.7 centimeters per year (cm/yr). He is at tanner 3. His insulin like growth factor 1 (IGF1) was 297 and insulin like growth factor binding protein 3 (IGFBP3) was 3.62.

His weight was 41.50 kilograms.
His height 150.5 cm (-2.24 standard deviation (SDS))
His mother's height is 160.02 cm and father's height is 162.56 cm and mid parental height is 167.8 cm (-1.26 SDS)
His predicted adult height is 171 cm, -0.81 SD.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society[1], the Lawson Wilkins Pediatric Endocrinology Society[2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists[4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the mid parental height; 3) height more than 2 SD below the mean and a height velocity over 1 yr more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10.

The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported and growth factors are normal.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."[10-13]

The patient had a pretreatment height of -2.24 SD. The patient's height velocity and bone age would allow the patient to reach a normal adult height. The patient therefore does not meet idiopathic short stature criteria.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.

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

The medical necessity for Norditropin FlexPro 10 milligram (mg)/1.5 milliliter (ml) SC SOPN is not substantiated.

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


Answer:
Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission

Answer:
This is an adult with a past medical history which includes diabetes mellitus. She presented to the emergency department (ED) with 2 days of intermittent palpitations, dizziness, and fatigue. She denied chest pain or shortness of breath. She noted a cough ongoing for 6 weeks. There were various laboratory abnormalities noted, including hypokalemia, elevated blood glucose, and elevated troponin of 165.9. There were no ischemic electrocardiogram (EKG) changes but left ventricular hypertrophy (LVH) was noted. Her workup was normal, including stress testing and echocardiography, although troponin remained elevated.

The patient had an admission diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Troponin was reported as elevated (and was, in fact high at 165.9). EKG showed LVH but no ischemic findings. Admission to telemetry was arranged.

Context:
Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is an adult with a past medical history which includes diabetes mellitus. She presented to the emergency department (ED) with 2 days of intermittent palpitations, dizziness, and fatigue. She denied chest pain or shortness of breath. She noted a cough ongoing for 6 weeks. There were various laboratory abnormalities noted, including hypokalemia, elevated blood glucose, and elevated troponin of 165.9. There were no ischemic electrocardiogram (EKG) changes but left ventricular hypertrophy (LVH) was noted. Her workup was normal, including stress testing and echocardiography, although troponin remained elevated.

The patient had an admission diagnosis of non-ST-elevation myocardial infarction (NSTEMI). Troponin was reported as elevated (and was, in fact high at 165.9). EKG showed LVH but no ischemic findings. Admission to telemetry was arranged.

A hospital admission was appropriate. When deciding on admission from the ED, the HEART score (History, Electrocardiogram (EKG), Age, Risk Factors, and Troponin) is commonly used. This score has been clinically validated and is described as "an internationally accepted risk stratification tool." The patient had a HEART score of 4 (one point each for history, age, risk factors, and troponin). This score is considered moderate risk, and associated with a 12-17% likelihood of MACE (major adverse cardiac event) over the following six weeks, and would have led to a recommendation for "the potential consideration of observation and further testing" from the ED.

For type 1 Myocardial Infarction (MI), admission, and cardiac catheterization with revascularization as necessary are standard treatment. This was a reasonable likelihood in this case at the time of admission. Fortunately, the workup was reassuring.

Alternatively, if type 2 MI was diagnosed, hospitalization still would have been warranted. The appropriate treatment for a type 2 MI is to treat the underlying condition. While the underlying condition in this case was never uncovered, initial concern for an underlying arrhythmia, particularly a ventricular tachyarrhythmia, was warranted. Her troponin was elevated, and she was having palpitations. The troponin itself was not explained, particularly its persistent elevation without suspected infarction. Common conditions to explain this finding include renal failure, heart failure, sepsis, pulmonary embolism, or other conditions such as advanced age - none of which were present in this case.

Inpatient admission was medically necessary. Troponin elevation with normal EKG was consistent with non ST elevation myocardial infarction (NSTEMI). The workup and intervention for this condition is typically intensive and prolonged. She was discharged to home immediately upon completion of a reasonable workup, minimizing her time in the hospital.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient hospital admission is substantiated.

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


Answer:
Diagnosis: Memory issues.
Treatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.

Answer:
This is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
There were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days.

Context:
Diagnosis: Memory issues.
Treatment: personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The insurer denied personal care aide level 2- 84 hours/week, 12 hours x 7 days.
The determination is upheld.

This is a female patient with a medical history notable for memory loss. The patient is approved for 3.5 hours 4 days per week and 3.25 hours 1 day per week (17.25 hours per week) of level 2 personal care aide services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and this request was denied by the health plan.
There were no letters of support or physician notes provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented times three with periods of forgetfulness. She was self-directing and able to make her needs known. For her instrumental activities of daily living (IADLs), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires extensive assistance for bathing. She requires limited assistance for dressing and toilet use. Other ADLs are independent. She is infrequently incontinent of urine. A task tool associated with the assessment recommended 15.76 hours per week to address her personal care needs. Compared to a prior assessment, she showed a modest decline in her functional status. At issue is the medical necessity of personal care aide level 2- 84 hours/week, 12 hours x 7 days.

The requested health service/treatment of personal care aide level 2- 84 hours/week, 12 hours x 7 days has not been demonstrated to be medically necessary for this patient.
The patient's UAS demonstrates that she needs assistance primarily with her IADLs but also with bathing. The task tool recommended 15.76 hours per week to address her needs, and she is currently approved for 17.25 hours per week. There was no evidence provided that the patient has any unmet personal care needs at her current level of service. There is, therefore, insufficient evidence for medical necessity for the requested increase.

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


Answer:
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.

Answer: This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro.

Context:
Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female patient diagnosed with type 2 diabetes mellitus (T2DM). This request is for Mounjaro. She states that she started metformin and then tried Ozempic and with both, she suffered adverse side effects. She failed metformin due to stomach cramping and almost daily diarrhea. She paid a subscription for Weight Watchers. She is using Mounjaro and doing well; her glycated hemoglobin (A1C) was 4.7 percent (%). Her A1C was 7.9 %.  She has obesity, anxiety and depression. She has been on Ozempic and her sugars improved and her weight is down but she had terrible gastrointestinal (GI) side effects, nausea and an upset stomach. It was not reported in this visit note that she has T2DM. At issue is the medical necessity of Mounjaro.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3).
There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists(4). The patient failed Ozempic. The patient can try one more formulary alternative. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.

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


Answer:
Diagnosis: Unilateral leg pain and weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

Answer:
This case involves a patient who presented to the hospital.  There was a history of obesity, diabetes mellitus, tobacco use, hypertension, prostate cancer, and cerebrovascular accident.  The patient presented with right-sided weakness that started 15 minutes prior.  The patient developed right-sided arm and leg weakness and associated numbness.  The symptoms had been intermittent for 2 days but became constant that day.  The patient reported severe back pain and multiple neurological symptoms in the past few weeks.  Vital signs of the patient were documented as blood pressure 157/117, temperature of 98.3 (degree) Fahrenheit, pulse of 80, respirations of 20, and oxygen saturation of 100% (percent) on room air.  The patient rated the pain 8 out of 10.  On exam, the patient appeared comfortable.  The patient was not ill or toxic appearing.  There was weakness present.  The patient had chronic left-sided facial droop.  The patient walked with a limp and dragged the right side.  The patient had decreased strength in the left upper extremity and left lower extremity with decreased sensation on the left side.  There was consideration for acute coronary syndrome, electrolyte disturbance, and transient ischemic attack versus cerebrovascular accident.  Neuroscience recommended admission for magnetic resonance imaging.  Imaging and laboratory work-up showed no acute findings.  The patient's white blood cell count was 7.1, hemoglobin was 12.6, hematocrit was 37.9, and creatinine was 1.07.  An electrocardiogram noted normal sinus rhythm and nonspecific T wave (interval on EKG [electrocardiogram]) abnormality.  The patient was given acetaminophen and ketorolac.  Magnetic resonance imaging of the brain did not show acute cerebrovascular accident.  Computed tomography angiography of the head and neck as well as computer tomography (CT) of the head did not show any large vessel occlusion.

It was stated that the inpatient hospital admission was not considered medically necessary as per Milliman Care Guidelines (MCG) stroke guidelines.

Answer: In this case, the patient presented to the hospital with acute right-sided arm and leg weakness.  The patient had a history of prior cerebrovascular accident with chronic left-sided weakness.  Initial diagnostic work-up had been unrevealing.

Context:
Diagnosis: Unilateral leg pain and weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This case involves a patient who presented to the hospital.  There was a history of obesity, diabetes mellitus, tobacco use, hypertension, prostate cancer, and cerebrovascular accident.  The patient presented with right-sided weakness that started 15 minutes prior.  The patient developed right-sided arm and leg weakness and associated numbness.  The symptoms had been intermittent for 2 days but became constant that day.  The patient reported severe back pain and multiple neurological symptoms in the past few weeks.  Vital signs of the patient were documented as blood pressure 157/117, temperature of 98.3 (degree) Fahrenheit, pulse of 80, respirations of 20, and oxygen saturation of 100% (percent) on room air.  The patient rated the pain 8 out of 10.  On exam, the patient appeared comfortable.  The patient was not ill or toxic appearing.  There was weakness present.  The patient had chronic left-sided facial droop.  The patient walked with a limp and dragged the right side.  The patient had decreased strength in the left upper extremity and left lower extremity with decreased sensation on the left side.  There was consideration for acute coronary syndrome, electrolyte disturbance, and transient ischemic attack versus cerebrovascular accident.  Neuroscience recommended admission for magnetic resonance imaging.  Imaging and laboratory work-up showed no acute findings.  The patient's white blood cell count was 7.1, hemoglobin was 12.6, hematocrit was 37.9, and creatinine was 1.07.  An electrocardiogram noted normal sinus rhythm and nonspecific T wave (interval on EKG [electrocardiogram]) abnormality.  The patient was given acetaminophen and ketorolac.  Magnetic resonance imaging of the brain did not show acute cerebrovascular accident.  Computed tomography angiography of the head and neck as well as computer tomography (CT) of the head did not show any large vessel occlusion.

It was stated that the inpatient hospital admission was not considered medically necessary as per Milliman Care Guidelines (MCG) stroke guidelines.  The patient did not have neurological findings that warranted inpatient care.  The patient could have been placed in observation under monitoring, had an evaluation, had testing completed, and been treated symptomatically while awaiting test results.  Consultation with other professionals could have been done in observation.  There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care.

Per the cited references, admission for suspected transient ischemic attack is indicated for patients with hemodynamic instability that persists despite appropriate treatment, when focal neurological signs recur, when there are findings on brain imaging that requires inpatient care, when there is altered mental status, when there cardiac arrhythmias of immediate concern, when clinically significant cardiac or vascular disorder is identified, for severe hypertension with systolic blood pressure greater than 180 or diastolic blood pressure greater than 120, when prolonged cardiac telemetry monitoring is needed beyond observation care timeframe, for suspected vasculitis, and when parenteral anticoagulation is required.  In this case, the patient presented to the hospital with acute right-sided arm and leg weakness.  The patient had a history of prior cerebrovascular accident with chronic left-sided weakness.  Initial diagnostic work-up had been unrevealing.  The documentation did not support that the patient had failed observation level of care or had acute indications for inpatient level of care.

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

The medical necessity for inpatient hospital admission is not substantiated.

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


Answer:
Diagnosis: Intrahepatic bile duct carcinoma.
Treatment: Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.
The insurer denied Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.

Answer:
This is a male patient with a medical history notable for intrahepatic bile duct carcinoma and dementia. The patient is currently residing in a skilled nursing facility and his care team is attempting a discharge home. He was approved for 9.5 hours per day, 7 days per week (66.5 hours per week) of personal care aide level 2 services. The patient's care team requested an increase to 24 hour per day split-shift personal care, 7 days per week (168 hours per week) and the request was denied by the health plan.
The patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill from intrahepatic bile duct carcinoma with an expected life expectancy of six months or less. He needs total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) and is mostly bedbound. He is nonverbal and unable to direct his own care. He is currently living in a nursing facility. His family lives out of state and cannot assist with care. He has a neighbor in his building that has volunteered to assist with medication management (as home health aides are not permitted to administer medication).
Hospice nurse notes were provided for review. Pressure reduction measures were recommended for the patient, including reposition and turn at least every 2 hours. He did not have any evidence of skin breakdown as evidenced by this care being provided in the nursing facility.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert but non-verbal and unable to interact; cognition was impaired. For Instrumental activities of daily living (IADL), the patient requires total dependence for essentially all. For his activities of daily living (ADL's), the patient requires total dependence or maximal assistance for all. He is bed bound and cannot direct his care; the nursing facility staff assists with all activities and directs care. He did not have any skin breakdown. He was frequently incontinent of stool and urine and wears diapers/chux pads for episodes of incontinence. At issue is the medical necessity of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.

Answer: The patient is receiving end-of-life hospice care. His dementia is advanced to the point of being nonverbal. He is not able to complete any ADLs or IADLs without human assistance, including bed-mobility. He must be turned and repositioned every 2 hours throughout the day and night to prevent skin breakdown. He is frequently incontinent of stool and urine and cannot direct his own diaper changes

Context:
Diagnosis: Intrahepatic bile duct carcinoma.
Treatment: Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.
The insurer denied Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.
The determination is overturned.

This is a male patient with a medical history notable for intrahepatic bile duct carcinoma and dementia. The patient is currently residing in a skilled nursing facility and his care team is attempting a discharge home. He was approved for 9.5 hours per day, 7 days per week (66.5 hours per week) of personal care aide level 2 services. The patient's care team requested an increase to 24 hour per day split-shift personal care, 7 days per week (168 hours per week) and the request was denied by the health plan.
The patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill from intrahepatic bile duct carcinoma with an expected life expectancy of six months or less. He needs total assistance with all activities of daily living (ADL) and Instrumental activities of daily living (IADL) and is mostly bedbound. He is nonverbal and unable to direct his own care. He is currently living in a nursing facility. His family lives out of state and cannot assist with care. He has a neighbor in his building that has volunteered to assist with medication management (as home health aides are not permitted to administer medication).
Hospice nurse notes were provided for review. Pressure reduction measures were recommended for the patient, including reposition and turn at least every 2 hours. He did not have any evidence of skin breakdown as evidenced by this care being provided in the nursing facility.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was alert but non-verbal and unable to interact; cognition was impaired. For Instrumental activities of daily living (IADL), the patient requires total dependence for essentially all. For his activities of daily living (ADL's), the patient requires total dependence or maximal assistance for all. He is bed bound and cannot direct his care; the nursing facility staff assists with all activities and directs care. He did not have any skin breakdown. He was frequently incontinent of stool and urine and wears diapers/chux pads for episodes of incontinence. At issue is the medical necessity of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week.

The requested health service of Personal Care Aide Level 2: 12 Hours/Day - 7 day(s) per week; 12 Hours/Day - 7 day(s) per week - 168 Hours per week is medically necessary for this patient.
The patient is receiving end-of-life hospice care. His dementia is advanced to the point of being nonverbal. He is not able to complete any ADLs or IADLs without human assistance, including bed-mobility. He must be turned and repositioned every 2 hours throughout the day and night to prevent skin breakdown. He is frequently incontinent of stool and urine and cannot direct his own diaper changes; he will require frequent checking and changes throughout the day and night. By definition, the patient's care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, the requested increase to 24 hour split-shift personal care is medically necessary and reasonable for the patient.

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


Answer:
Diagnosis: Alcohol abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

Answer: The patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication.

Answer: The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival.

Context:
Diagnosis: Alcohol abuse.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male who initially presented to the emergency department with request for alcohol detoxification. Pertinent history included diabetes mellitus, alcohol use, and smoking crack. No history of alcohol withdrawal seizure or delirium tremens are noted. Initial vital signs revealed a temperature of 97.5F (Fahrenheit), heart rate (HR) 81, blood pressure (BP) 112/71, respiratory rate (RR) 18, and oxygen saturation 100% on room air. Initial examination documented the patient as alert and oriented with evidence of acute intoxication.

The inpatient hospital admission was not medically necessary. The patient had a history of alcohol use disorder without prior withdrawal seizures or delirium tremens who presented with acute alcohol intoxication requesting detoxification. Initial examination documented the patient as alert, oriented, and with stable hemodynamics. Initial evaluation was relatively unremarkable with the exception of hyponatremia. Treatment included intravenous fluids and CIWA (Clinical Institute Withdrawal Assessment) with benzodiazepines as needed. Following observation care, the CIWA was documented as 0 and no benzodiazepines had been indicated / administered for a 24 hour period. The patient was deemed medically stable for discharge with a similar serum sodium level as on arrival. No other issues or complications were documented. A lower level of care was appropriate.

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


Answer:
Diagnosis: back surgery
Treatment: inpatient stay
The insurer denied an inpatient stay.

Answer: The patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed.

Answer: Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care.

Context:
Diagnosis: back surgery
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned.

The patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed. No complications were reported. Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care.

The inpatient hospital admission was medically necessary.
The patient underwent a L (lumbar) 4-S (sacral) 1 fusion. She experienced no complications post-operatively. She was able to be safely discharged home on postoperative day (POD) 4 after expected recovery as an inpatient in the hospital. Lumbar fusion benchmark length of stay is 1-3 days and standard of care is to perform this as an inpatient. Given the invasive nature of this major surgical procedure and the necessary post-operative care as per above, inpatient care was medically necessary post-operatively. The treatment received was within generally accepted standards of medical practice and would be clinically appropriate at the inpatient level of care. The patient does not meet a lower level of care due to the complexity of her procedure and necessary care as per above. Therefore, inpatient admission on the denied days was medically necessary.

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


Answer:
Diagnosis: Viral pharyngitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.

Answer: This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

Context:
Diagnosis: Viral pharyngitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) a sore throat associated with a fever. Imaging studies included a chest x-ray (CXR) which showed possible right lower lobe (RLL) community acquired pneumonia (CAP), a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no acute pathology, a CT scan of the chest showed no pneumonia. The patient was diagnosed with CAP and treated with intravenous (IV) antibiotics and intravenous fluids (IVF), but was eventually diagnosed with viral pharyngitis and antibiotics were discontinued. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) a sore throat associated with fever. The patient was initially diagnosed with CAP and treated with antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, uremia, respiratory rate, blood pressure (BP), age greater than or equal to (>=) 65 years) score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable. The patient was ultimately diagnosed with viral pharyngitis and treated with IV fluids and antibiotics were discontinued, and overall care could have been safely provided at a lower level of care.

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


Answer:
Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.

Answer: This is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits.

Context:
Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is overturned.

This is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits.

Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2)
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with a normal occlusion. (3) It has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. (3) Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.

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


Answer:
Diagnosis: Throat infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

Answer:
The patient is seeking coverage for inpatient admission due to throat infection.  The patient presented to the hospital complaining of sore throat and difficulty swallowing.  The symptoms started approximately 4 days prior while they were traveling.  The patient had presented to the emergency department (ED) and tested negative for mononucleosis and streptococcus.  Computed tomography (CT) showed pharyngitis and tonsillitis.  The patient was treated with amoxicillin and prednisone.  However, their symptoms continued to progress.  Vitals signs noted blood pressure of 92/54, pulse of 88, respirations of 28, temperature of 97.7 degrees Fahrenheit, and oxygen saturation of 99% (percent) on room air.  Laboratory results noted white blood cell (WBC) count of 8.0, red blood cell count of 4.42, hemoglobin of 14.3, creatinine of 0.78, glucose of 109, potassium of 3.9, and sodium of 135.  The patient was given a dose of Decadron 10 milligrams (mg) on 2 consecutive days with significant improvement in pain and swelling.  The physical exam noted erythematous tonsils that were 3+ with exudates.  There was cervical adenopathy.  The patient was continued on intravenous (IV) fluids which were weaned as their oral intake improved.  The patient was given intravenous Unasyn every 6 hours which was transitioned to Augmentin at discharge.  The patient was given a dose of 500 mg of ceftriaxone intravenous for presumptive treatment of Neisseria gonorrhea.  It was indicated that the patient may need tonsillar removal after the infection is resolved.  There was a plan for follow-up in 2 to 3 days with the primary care provider.  The patient was deemed appropriate for discharge.

It was argued by the hospital that the inpatient admission due to throat infection was medically necessary.  A summary of the patient's admission is detailed.  The patient presented to the emergency department with muffled voice, odynophagia, and sore throat.  The patient had previously been seen at another emergency department.  The patient had been taking amoxicillin and prednisone with worsening symptoms.  The patient reported difficulty swallowing the medication.  The patient was hypotensive at 92/54 and received 2 liters of intravenous fluid.  The patient was admitted to the hospital and received intravenous Unasyn every 6 hours and intravenous Decadron twice.  The patient also received intravenous fluids for greater than 24 hours.

Context:
Diagnosis: Throat infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is seeking coverage for inpatient admission due to throat infection.  The patient presented to the hospital complaining of sore throat and difficulty swallowing.  The symptoms started approximately 4 days prior while they were traveling.  The patient had presented to the emergency department (ED) and tested negative for mononucleosis and streptococcus.  Computed tomography (CT) showed pharyngitis and tonsillitis.  The patient was treated with amoxicillin and prednisone.  However, their symptoms continued to progress.  Vitals signs noted blood pressure of 92/54, pulse of 88, respirations of 28, temperature of 97.7 degrees Fahrenheit, and oxygen saturation of 99% (percent) on room air.  Laboratory results noted white blood cell (WBC) count of 8.0, red blood cell count of 4.42, hemoglobin of 14.3, creatinine of 0.78, glucose of 109, potassium of 3.9, and sodium of 135.  The patient was given a dose of Decadron 10 milligrams (mg) on 2 consecutive days with significant improvement in pain and swelling.  The physical exam noted erythematous tonsils that were 3+ with exudates.  There was cervical adenopathy.  The patient was continued on intravenous (IV) fluids which were weaned as their oral intake improved.  The patient was given intravenous Unasyn every 6 hours which was transitioned to Augmentin at discharge.  The patient was given a dose of 500 mg of ceftriaxone intravenous for presumptive treatment of Neisseria gonorrhea.  It was indicated that the patient may need tonsillar removal after the infection is resolved.  There was a plan for follow-up in 2 to 3 days with the primary care provider.  The patient was deemed appropriate for discharge.

It was argued by the hospital that the inpatient admission due to throat infection was medically necessary.  A summary of the patient's admission is detailed.  The patient presented to the emergency department with muffled voice, odynophagia, and sore throat.  The patient had previously been seen at another emergency department.  The patient had been taking amoxicillin and prednisone with worsening symptoms.  The patient reported difficulty swallowing the medication.  The patient was hypotensive at 92/54 and received 2 liters of intravenous fluid.  The patient was admitted to the hospital and received intravenous Unasyn every 6 hours and intravenous Decadron twice.  The patient also received intravenous fluids for greater than 24 hours.

Per the cited guidelines, admission to the hospital for tonsillitis may be indicated when there is hemodynamic instability such as with hypotension that persist despite appropriate treatment, when there is airway obstruction or impending obstruction, when there is extension of infection into the deep tissues of the neck or superior mediastinum, when surgical drainage is needed that cannot be performed in observation care, or for thrombophlebitis of internal jugular vein.  In this case, the patient was admitted to the hospital due to suspected throat infection/tonsillitis with swelling.  While it is noted that the patient had hypotension, this responded to intravenous fluids.  The patient did not have hemodynamic instability such as with hypotension that persisted despite appropriate treatment, airway obstruction or impending obstruction, extension of infection into the deep tissues of the neck or superior mediastinum, a need for surgical drainage which could not be performed in observation care, or evidence of thrombophlebitis of internal jugular vein.  Thus, the patient's care could have been completed at a lower level such as observation.

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

The medical necessity for inpatient admission due to throat infection is not substantiated.

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


Answer:
Diagnosis: Dementia

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week

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

Answer:
The patient is diagnosed with Alzheimer's disease, unspecified under hospice care for end stage dementia. The patient lives with their spouse in a 2-bedroom apartment.

On the Uniform Assessment System New York (UAS-NY) Assessment, the patient's spouse requested an increase because the patient is experiencing weakness and the inability to walk. Based on the assessment the patient's current declines were noted as dressing upper body- maximal assistance; personal hygiene- maximal assistance; walking- total assistance; and locomotion- total assistance. The patient is able to take care of their toileting needs and transfer on and off the toilet with assistance; bathe themselves with assistance; and take medications with assistance from their spouse. The patient's spouse is supportive and involved in the patient's care. The patient has incontinent supplies, gloves, glucometer, Personal Emergency Response System (PERS), cane, shower chair, shower grab bar, bedside commode, walker, wheelchair, and hospital bed in your home that can assist you with your needs. The patient was recently in the hospital for altered mental status and for high blood pressure.

The statement of support for an external appeal for Personal Care Aide services noted that the patient's spouse is frail and weak and can no longer provide for the patient's care need. It was also noted that the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers.

The statement of homebound status noted that the patient is bedbound, non-ambulatory and unable travel to a hearing by any means including public transportation.

Answer: the patient has had frequent hospital admission due to urinary tract infection (UTI), sepsis and altered mental status, and falls

Answer: the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers

Context:
Diagnosis: Dementia

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week

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

The denial is overturned

The patient is diagnosed with Alzheimer's disease, unspecified under hospice care for end stage dementia. The patient lives with their spouse in a 2-bedroom apartment.

On the Uniform Assessment System New York (UAS-NY) Assessment, the patient's spouse requested an increase because the patient is experiencing weakness and the inability to walk. Based on the assessment the patient's current declines were noted as dressing upper body- maximal assistance; personal hygiene- maximal assistance; walking- total assistance; and locomotion- total assistance. The patient is able to take care of their toileting needs and transfer on and off the toilet with assistance; bathe themselves with assistance; and take medications with assistance from their spouse. The patient's spouse is supportive and involved in the patient's care. The patient has incontinent supplies, gloves, glucometer, Personal Emergency Response System (PERS), cane, shower chair, shower grab bar, bedside commode, walker, wheelchair, and hospital bed in your home that can assist you with your needs. The patient was recently in the hospital for altered mental status and for high blood pressure.

The statement of support for an external appeal for Personal Care Aide services noted that the patient's spouse is frail and weak and can no longer provide for the patient's care need. It was also noted that the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers.

The statement of homebound status noted that the patient is bedbound, non-ambulatory and unable travel to a hearing by any means including public transportation.

Per the cited references, personal care services are the provision of some or total assistance with personal hygiene, dressing, and feeding and nutritional and environmental support. The services must be essential to the maintenance of the patient's health and safety in their home, be ordered by physician or nurse practitioner, and be based on an assessment of the patient's needs for the service in accordance with guidelines. Based on the assessment, the provider's declaration and the statement letter of supporting information the patient will requires additional personal assistance due to the current change and decline in functional status and the inability for the continued care from the primary caregiver. In addition, the patient has had frequent hospital admission due to urinary tract infection (UTI), sepsis and altered mental status, and falls; therefore, additional assistance is supported. Furthermore, the patient cannot physically or cognitively assist with toileting needs, transfers on or off the toilet and is dependent on diapers and is thus at risk for skin breakdown. The need for toileting in view of the patient's deterioration is unpredictable.

As such, the request for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week is overturned as medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day, 7 days per week, 12 hours per day, 7 days per week (Split Shift) a total of 168 hours per week services is substantiated.

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