Answer: This male infant was born several weeks premature weighing 2630 grams; delivery was via spontaneous vaginal delivery complicated by Group B Streptococcus (GBS) and premature rupture of membranes (PROM).   The Neonatal Intensive Care Unit (NICU) admission was initially for preterm gestation and presumed sepsis.  As of Day #3, the patient was in room air without distress and with normal vital signs.  Fluids and nutrition were being provided by both enteral and intravenous (IV) routes with oral (p.o.) feeding gradually increased and IV fluid gradually decreased.  IV antibiotics had been started for presumed sepsis; the blood culture showed no growth to date.  Phototherapy was started for hyperbilirubinemia of prematurity, but discontinued 12 hours later.  On Day #4, antibiotics were discontinued. Feeding was advanced and IV fluid was decreased. On Day #7 IV fluid was discontinued. Bilateral casts were placed for club feet.  On Day #8 the infant was on p.o. feeding without any significant co-morbidity requiring treatment.

Answer:
Diagnosis: Prematurity

Treatment: Inpatient admission, medication, monitoring, phototherapy

Answer: The insurer denied the continued NICU level of care.

Context:
Diagnosis: Prematurity

Treatment: Inpatient admission, medication, monitoring, phototherapy

The insurer denied the continued NICU level of care. The denial was reversed.

This male infant was born several weeks premature weighing 2630 grams; delivery was via spontaneous vaginal delivery complicated by Group B Streptococcus (GBS) and premature rupture of membranes (PROM).   The Neonatal Intensive Care Unit (NICU) admission was initially for preterm gestation and presumed sepsis.  As of Day #3, the patient was in room air without distress and with normal vital signs.  Fluids and nutrition were being provided by both enteral and intravenous (IV) routes with oral (p.o.) feeding gradually increased and IV fluid gradually decreased.  IV antibiotics had been started for presumed sepsis; the blood culture showed no growth to date.  Phototherapy was started for hyperbilirubinemia of prematurity, but discontinued 12 hours later.  On Day #4, antibiotics were discontinued. Feeding was advanced and IV fluid was decreased. On Day #7 IV fluid was discontinued. Bilateral casts were placed for club feet.  On Day #8 the infant was on p.o. feeding without any significant co-morbidity requiring treatment.

According to MCG: Neonatal Care, Intermediate Care, Level 3 (LOC:012): Admission for or continuation (from higher level) of care at Level 3 indicated by: inadequate feedings (e.g., oral and nasogastric) requiring ongoing IV fluids. According to MCG: Neonatal Care, Continuing Care, Level 2 (LOC: 011):  Admission for or continuation (from higher level) of care at Level 2 indicated by presence of: Care for mild instability or condition as indicated by 1 or more of the following: Continued inpatient care during convalescence from condition or conditions treated at higher level of care; Limited or absent oral feedings requiring efforts to advance toward expected oral goal; Suspected sepsis: evaluation and observation of asymptomatic infant; Neonatal jaundice requiring monitoring (e.g., elevated bilirubin levels repeated more frequently than every 12 hours) or treatment with phototherapy; Supportive care needed for other instability or condition.

Care at Neonatal Care, Intermediate Care, Level 3 is approved for Days #3-6, and care at Neonatal Care, Continuing Care, Level 2 is approved for the remainder of stay. The carrier's denial of inpatient hospital services at the Neonatal Intensive Care Unit level of care is reversed.

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


Answer: This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal.

Answer: She presented with a new onset of atrial fibrillation (AF).

Context:
This is a patient with a history of diabetes, hypertension, hyperlipidemia, asthma, pulmonary embolism and obstructive sleep apnea. She presented to the emergency department complaining of chest tightness, dyspnea, palpitations and cough. Her blood pressure was 150/120 millimeters of mercury (mmHg) with a heart rate of 160 beats/minute. Room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and a rapid, irregular rhythm. An electrocardiogram showed atrial fibrillation with a rapid ventricular rate and nonspecific repolarization changes. Her serum troponin level was normal. The health plan's determination of medical necessity is upheld. She presented with a new onset of atrial fibrillation (AF). She was hemodynamically stable and there was no evidence of myocardial ischemia or decompensated heart failure. In patients who present to the emergency department with acute AF, the safety of a lower level care or discharge to home with close follow-up has been well demonstrated.
Per the Milliman Care Guideline for Atrial Fibrillation (ORG: M-505) , indications for inpatient care include: hemodynamic instability, myocardial infarction or ischemia, altered mental status, syncope, heart failure, implantable cardioverter defibrillator discharges, Wolff Parkinson White syndrome, medication toxicity, severe electrolyte or acid base disturbance or other acute serious medical condition requiring inpatient care, need for initiation of antiarrhythmic drug therapy in a patient at high risk for adverse effects, persistent symptomatic tachycardia despite outpatient or observation level care or need for urgent or elective cardioversion that cannot be performed on an outpatient basis or during observation care. This patient met none of these criteria.

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


Answer:
Diagnosis: Abdominal Pain
Treatment: Inpatient admission

Answer: This patient presented with signs and symptoms of acute cholecystitis with confirmatory diagnostic imaging. There were no signs and symptoms of sepsis and no untoward events during or after surgery. All available laboratory data was trending downward after the infected organ was removed.

Context:
Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The proposed inpatient treatment was not medically necessary.

After an uncomplicated elective laparoscopic cholecystectomy, patients can drink clear liquids once awake from anesthesia, and their diet can be advanced as tolerated.

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class IV, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

This patient presented with signs and symptoms of acute cholecystitis with confirmatory diagnostic imaging. There were no signs and symptoms of sepsis and no untoward events during or after surgery. All available laboratory data was trending downward after the infected organ was removed.  Therefore, the inpatient admission was not medically necessary.

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


Answer: This is a patient with a history of malignant melanoma in situ on the left neck and right deltoid, and a history of malignant melanoma to the left scapula, Breslow 0.7 millimeter (mm). There is no ulceration and the mitotic index is less than one. This is a review for coverage of the DecisionDX melanoma assay.

Context:
This is a patient with a history of malignant melanoma in situ on the left neck and right deltoid, and a history of malignant melanoma to the left scapula, Breslow 0.7 millimeter (mm). There is no ulceration and the mitotic index is less than one. This is a review for coverage of the DecisionDX melanoma assay.

The health plan's determination is upheld. The DecisionDX melanoma testing is not likely to be more beneficial than any standard treatment for the patient's condition. There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. There is insufficient clinical evidence in the peer-reviewed medical literature to demonstrate improved long-term health outcomes of this testing.

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


Answer: of

Answer: The patient has a history of Malignant Melanoma of the left medial scapula that was biopsied on 5/17/2017. The Melanoma was read out as having a Breslow depth of 0.7 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field. Regression was noted, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a. The DecisionDx-Melanoma Gene Expression Assay is under review.

Context:
The patient has a history of Malignant Melanoma of the left medial scapula that was biopsied on 5/17/2017. The Melanoma was read out as having a Breslow depth of 0.7 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field. Regression was noted, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a. The DecisionDx-Melanoma Gene Expression Assay is under review.

The health plan's determination is upheld. The DecisionDx-Melanoma test is not likely to be more beneficial than standard treatment in this case. It is not in accordance with generally accepted standards of medical practice in the United States, and is not clinically appropriate for this patient's clinical condition. Standard treatment in this case is observation and followup based on the tumor's histologic features. This patient has a relatively superficial melanoma with no ulceration or significant number of dermal mitoses, so that wide excision and appropriate followup only is indicated for this patient. Therefore, at this time, the DecisionDx-Melanoma is not likely to be more beneficial than standard treatment in this case. The only consensus that exists for this test is that more studies need to occur in modern evidence-based and peer-reviewed literature.

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


Answer: The patient has a cutaneous melanoma to the back, 0.7 millimeter (mm) in depth with absent ulceration. DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years). The use of the DecisionDx testing is under review.

Context:
The patient has a cutaneous melanoma to the back, 0.7 millimeter (mm) in depth with absent ulceration. DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years). The use of the DecisionDx testing is under review.

The health plan's determination is upheld. There is no evidence based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care and there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma. Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing. For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care.

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


Answer:
Diagnosis: Constipation, tenesmus, bowel leakage
Treatment: Hospital Emergency Admission

Answer: The patient has human immunodeficiency virus and rectal squamous cell carcinoma status post chemotherapy and radiation.  He presented to the hospital with one week of constipation, tenesmus, and bowel leakage.

Answer: The patient was afebrile with a blood pressure of 135/83.  Labs demonstrated a creatinine of 2.0, potassium of 6.1, bicarbonate of 21, magnesium of 1.4, and white blood cell count of 10,400.  Computed tomography (CT) of the abdomen/pelvis demonstrated perirectal fat stranding in the rectal area suggestive of proctitis.  Intravenous fluids, magnesium supplementation, and as needed analgesics were ordered.  One dose each of prednisone and azithromycin were administered for treatment of gonorrhea and chlamydia.  The potassium normalized, and the creatinine dropped to 1.4.  Hydrocortisone suppositories were provided.

Context:
Diagnosis: Constipation, tenesmus, bowel leakage
Treatment: Hospital Emergency Admission

The hospital emergency admission was not medically necessary.

The patient has human immunodeficiency virus and rectal squamous cell carcinoma status post chemotherapy and radiation.  He presented to the hospital with one week of constipation, tenesmus, and bowel leakage.

The patient was afebrile with a blood pressure of 135/83.  Labs demonstrated a creatinine of 2.0, potassium of 6.1, bicarbonate of 21, magnesium of 1.4, and white blood cell count of 10,400.  Computed tomography (CT) of the abdomen/pelvis demonstrated perirectal fat stranding in the rectal area suggestive of proctitis.  Intravenous fluids, magnesium supplementation, and as needed analgesics were ordered.  One dose each of prednisone and azithromycin were administered for treatment of gonorrhea and chlamydia.  The potassium normalized, and the creatinine dropped to 1.4.  Hydrocortisone suppositories were provided.

The patient presented to the hospital with proctitis but did not have inflammatory bowel disease, gastrointestinal bleed, fever, hemodynamic instability, or evidence of bowel obstruction.  No surgical intervention was required.  The patient had only a mild degree of acute kidney injury, and renal function improved promptly with administration of intravenous fluids.  The patient's hyperkalemia was mild and was not associated with muscle weakness, ventricular arrhythmia, or electrocardiographic changes.  The potassium normalized with intravenous fluid administration.  In summary, inpatient admission was not medically necessary.

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


Answer: This is a male patient who underwent a sleep study in early 2019 with decreased oxygen saturation indicative of severe obstructive sleep apnea.  The patient is symptomatic with nonrestorative sleep and excessive daytime somnolence.  A contributing factor to the obstructive sleep apnea is a significant anatomic abnormality in the patient's upper airway with evidence of prior horizontal nasal fracture and severe nasal septum deviations with multiple perforations.  The physician detailed that the first therapeutic modality would be considered continuous positive airway pressure (CPAP) trial with an attended in lab CPAP titration. The notes also indicate that the patient is being treated by a cardiologist for an aortic bicuspid valve.

Answer: Diagnosis: Severe Obstructive Sleep Apnea

Answer: Treatment:  Laboratory based Sleep Study

Answer: The insurer denied the laboratory based Sleep Study.

Context:
Diagnosis: Severe Obstructive Sleep Apnea

Treatment:  Laboratory based Sleep Study

The insurer denied the laboratory based Sleep Study.  The denial was reversed.

This is a male patient who underwent a sleep study in early 2019 with decreased oxygen saturation indicative of severe obstructive sleep apnea.  The patient is symptomatic with nonrestorative sleep and excessive daytime somnolence.  A contributing factor to the obstructive sleep apnea is a significant anatomic abnormality in the patient's upper airway with evidence of prior horizontal nasal fracture and severe nasal septum deviations with multiple perforations.  The physician detailed that the first therapeutic modality would be considered continuous positive airway pressure (CPAP) trial with an attended in lab CPAP titration. The notes also indicate that the patient is being treated by a cardiologist for an aortic bicuspid valve.

Home-based sleep studies with portable monitors are preferred over in-laboratory polysomnography, except in those patients who have contraindications to a home sleep study. The patient has previously undergone a sleep study and he was diagnosed with severe obstructive sleep apnea. He is also being monitored by cardiology for an aortic bicuspid valve. He recently had a major facial injury as well with evidence of a prior horizontal nasal fracture, severe nasal septum deviations and multiple perforations.  Therefore, the patient would need to be monitored in a facility with supervision from a trained professional in order to optimize the CPAP and monitor the titration.

Based on the above, the medical necessity for a laboratory-based sleep study is substantiated.  The insurer's denial is reversed.

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


Answer:
Diagnosis:  Migraines
Issue under review:  Zembrace

Context:
Diagnosis:  Migraines
Issue under review:  Zembrace

Determination:
The Zembrace is not medically necessary.

There is no documented reason as to why the patient cannot be treated with the preferred formulary agents.  The patient can be treated with sublingual disintegrating triptans.  There is no evidence from high quality clinical trials or support from standard of care guidelines for the preferential use or superiority of Zembrace relative to the preferred agents.  The patient can be treated with sublingual disintegrating triptans.

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


Answer: the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.

Answer: Diagnosis: Class I malocclusion, and anterior crossbite with gingival attachment loss (canines)

Answer: Treatment: Braces

Answer: The insurer has denied coverage for braces.

Answer: This patient is a child.

Answer: this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, and anterior crossbite with gingival attachment loss (canines). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by internal reviewers.

Answer: it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the HLD Index Report (HLD, New York State Medicaid program) modeled after HLD Index.

Context:
Diagnosis: Class I malocclusion, and anterior crossbite with gingival attachment loss (canines)

Treatment: Braces

The insurer has denied coverage for braces. The denial was reversed.

This patient is a child. Upon review of the submitted documentation, including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, peer reviewed literature, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, and anterior crossbite with gingival attachment loss (canines). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 8 points on review by internal reviewers.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the HLD Index Report (HLD, New York State Medicaid program) modeled after HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.  Regarding the validity of the HLD Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies including:

Beglin, et al. A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need. Am J Orthod Dentofacial Orthoped 2001; 120: 240-6,

Parker. A study of 1000 malocclusions selected by the HLD Index. Am J Orthod Dentofacial Orthoped 1999; 115:343-51,

Theis, et al. Eligibility for publically funded orthodontic treatment determined by the handicapping labiolingual deviation index. Am J Orthod Dentofacial Orthoped 2005; 128:708-15.

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

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. The healthcare plan did not act reasonably or with sound medical judgment or the best interest of the patient.

Based on the above, the medical necessity for braces is substantiated.  The insurer's denial is reversed.

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


Answer:
Diagnosis: Varicose veins
Treatment: Stab phlebectomy

Answer: The primary basis for denial is that "documentation does not show the treatment to be performed concurrently with or after saphenous vein stripping or ablation per required criteria". The requirement that phlebectomy can only be done concurrently with or after saphenous vein stripping or ablation exists in the health plan policy.

Answer: The provider (AP) has proposed left leg phlebectomy for this patient who has minimal axial saphenous reflux.

Answer: The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux in separate segments of the greater saphenous vein.

Answer: The physician has documented that the veins to be treated are ropey. The venous duplex also confirms the presence of varicosities in both legs.

Answer: The record shows that the patient has been using prescription-grade compression stockings regularly with only minimal relief of symptoms. She has undergone an unsuccessful, monitored trial of stockings.

Answer: The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function.

Context:
Diagnosis: Varicose veins
Treatment: Stab phlebectomy
The phlebectomy is medically necessary.

The primary basis for denial is that "documentation does not show the treatment to be performed concurrently with or after saphenous vein stripping or ablation per required criteria". The requirement that phlebectomy can only be done concurrently with or after saphenous vein stripping or ablation exists in the health plan policy. However, this requirement is not consistent with published clinical data or consensus guidelines for phlebectomy. When other criteria are met (see discussion below), phlebectomy is widely accepted as medically necessary in the absence of concurrent or prior saphenous ablation.

It should be noted that the denial letter incorrectly describes CPT 37785 as a code for sclerotherapy. The correct definition of this code is "Ligation, division, and/or excision of varicose vein cluster(s), 1 leg".  Additionally, the letter states that CPT 37799 is not the correct code for stab phlebectomy. This statement is incorrect. CPT 37799 (unlisted code) is the code that is supposed to be used for stab phlebectomy when fewer than ten stab incisions are used.  All of the codes requested by the provider are alternative codes for phlebectomy:
37766 is for phlebectomy with 20+ stab incisions
37765 is for phlebectomy with ten to 20 stab incisions
37799, the unlisted code, is used for phlebectomy with under ten stab incisions
37785 is used for phlebectomy of a single varicose vein cluster.

The provider (AP) has proposed left leg phlebectomy for this patient who has minimal axial saphenous reflux. In order to evaluate the medical necessity of the service, widely accepted standards will be applied [1-3]. Under these standards, phlebectomy is appropriate when:

a) There is no axial saphenous reflux, or any associated axial reflux has been treated. If axial reflux has been treated, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms.

b) The patient has symptoms of venous insufficiency severe enough to interfere with normal function.

c) The patient's varicose veins are large enough to account for the symptoms.

d) The patient has failed a trial of medical grade compression stockings.

Requirement (a) has been met. The patient's venous reflux study does not show clinically significant axial reflux. She has only focal reflux in separate segments of the greater saphenous vein.

Requirement (b) has been met. The office notes show that the patient has symptoms of venous insufficiency severe enough to adversely affect normal function. The appeal letter corroborates and elaborates upon the history reported in the office notes.

Requirement (c) has been met. The physician has documented that the veins to be treated are ropey. The venous duplex also confirms the presence of varicosities in both legs.

Requirement (d) has been met. The record shows that the patient has been using prescription-grade compression stockings regularly with only minimal relief of symptoms. She has undergone an unsuccessful, monitored trial of stockings.

Therefore, in summary, the patient meets published, well accepted criteria for performance of phlebotomy.

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


Answer: The patient is a male child who presented to the Emergency Room (ER) for left lateral neck and cheek swelling after having failed to show improvement of the swelling after being started on clindamycin by his primary care physician.  Physical examination in the ER revealed a large area of tenderness and swelling over the submandibular and parotid area.

Answer: A CT confirmed a left intraparotid 2.2 by 1.4 cm fluid collection consistent with abscess.

Answer: the left parotid gland was enlarged and inflamed, consistent with parotitis, indicating that the abscess was a complication of the parotitis. It was also a concern that the left internal jugular vein was compressed

Answer: It was ultimately evident that the parotid infection was caused by Strep pyogenes

Answer: the sonogram of the neck done soon after ER arrival had been even more concerning for a finding of a more than 3 by 2 by 2 cm mass with heterogeneous density fluid components which could have raised suspicion of a deep neck abscess.

Answer: a chest x-ray noted rightward tracheal deviation with concern for left-sided mass, which could possibly be mediastinal, if indeed there was a left-sided deep neck abscess.

Answer: There was leukocytosis at a level of 19,500 and an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicating a severe infection.

Answer: Diagnosis: Parotid abscess

Answer: Treatment: Inpatient admission

Answer: The insurer has denied inpatient admission.

Context:
Diagnosis: Parotid abscess

Treatment: Inpatient admission

The insurer has denied inpatient admission. The denial was reversed.

The patient is a male child who presented to the Emergency Room (ER) for left lateral neck and cheek swelling after having failed to show improvement of the swelling after being started on clindamycin by his primary care physician.  Physical examination in the ER revealed a large area of tenderness and swelling over the submandibular and parotid area. The patient clearly needed intravenous antibiotic therapy and close monitoring as an inpatient for possible spread of infection or possible airway compromise. The following facts support this determination:

A CT confirmed a left intraparotid 2.2 by 1.4 cm fluid collection consistent with abscess. Moreover, the left parotid gland was enlarged and inflamed, consistent with parotitis, indicating that the abscess was a complication of the parotitis. It was also a concern that the left internal jugular vein was compressed, which this reviewer assumes was from the parotid mass. Incidentally found were middle ear effusions with possible otomastoiditis, which is another bacterial infection that would require antibiotic therapy. In fact, the sonogram of the neck done soon after ER arrival had been even more concerning for a finding of a more than 3 by 2 by 2 cm mass with heterogeneous density fluid components which could have raised suspicion of a deep neck abscess. Moreover, a chest x-ray noted rightward tracheal deviation with concern for left-sided mass, which could possibly be mediastinal, if indeed there was a left-sided deep neck abscess. The history of Methicillin-resistant Staphylococcus aureus (MRSA) infection in the neonatal period was also significant; therefore, it was reasonable to include MRSA in the list of possible organisms causing the parotid abscess.  There was leukocytosis at a level of 19,500 and an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) indicating a severe infection.

It was ultimately evident that the parotid infection was caused by Strep pyogenes, which can be a rapidly progressing soft tissue infection and entails the risk of bacteremia in a young infant of this patient's age. The intravenous antibiotic regimen Vancomycin and Unasyn was standard of care.

In summary, the patient had significant co-morbidities with his bacterial parotid gland infection, and as supported by the review by Stong et al, "the presence of a significant co-morbidity, fever, or leukocytosis may require inpatient therapy and imaging if patients fail to improve with medical therapy."

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. The inpatient hospital service is considered medically necessary for this patient.

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

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


Answer:
Diagnosis: Lewy body dementia
Issue under review: Increase in PCW services

Answer: This is a patient with a history of advanced Lewy body dementia and associated psychosis.

Answer: the report from the patient's attending physician that the patient has sustained further cognitive and functional decline

Answer: a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date.

Context:
Diagnosis: Lewy body dementia
Issue under review: Increase in PCW services

Determination:
The Increase in PCW services is not medically necessary.

This is a patient with a history of advanced Lewy body dementia and associated psychosis.  Despite the report from the patient's attending physician that the patient has sustained further cognitive and functional decline, a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date.  Furthermore, her currently approved PCW service is sufficient to meet her ADLs and other needs.  For these reasons, the proposed treatment of an increase in PCW services is not deemed medically necessary.

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


Answer: Diagnosis: Migraines

Answer: Treatment: Medication- Emgality

Answer: The insurer denied coverage for Emgality.

Answer: This child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality.

Context:
Diagnosis: Migraines

Treatment: Medication- Emgality

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

This child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality.

Emgality will only be approved for adult patients. Furthermore, the patient must have had serious side-effects or drug failure to a 3-month trial of at least two medications- examples include Propranolol, Topiramate, Valproic Acid, Amitriptyline, Venlafaxine and Botox. There is no documentation that the patient has failed 2 preventative medications for migraines.

The patient's asthma is a contraindication to propranolol and other beta blockers.  Neurologist states that the patient cannot take amyitryptiline or nortryptiline because she is already taking two other antidepressants, though this is not an absolute contraindication. The patient has no contraindication to Topirimate, Valproate or Botox.

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


Answer: The patient in this case was using opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of cocaine

Answer: Diagnosis: Substance abuse

Answer: Treatment: Continued inpatient admission

Answer: the patient presented with moderately severe withdrawal symptoms that persisted

Answer: and the patient's social environment was not conducive to detoxification.

Answer: the patient struggled with withdrawal symptoms

Answer: in the context of limited insight, impaired judgment and poor control of impulses.

Context:
Diagnosis: Substance abuse

Treatment: Continued inpatient admission

The continued inpatient admission was medically necessary for this patient.
The requested benefit of the continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode, could not have safely or effectively proceeded at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with moderately severe withdrawal symptoms that persisted requiring withdrawal management, and the patient's social environment was not conducive to detoxification. Again, the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses. Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring.

The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission is medically necessary in this case scenario, and therefore should be covered in this case scenario. The health plan contends that the patient could have been treated at inpatient rehabilitation level of care. However, the patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria, referenced below.

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


Answer: This is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.

Answer: The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.

Answer: Diagnosis: Alopecia Areata and Vitiligo

Answer: Treatment: Xeljanz

Answer: The insurer denied the Xeljanz.

Answer: The patient has alopecia areata and vitiligo.

Context:
Diagnosis: Alopecia Areata and Vitiligo

Treatment: Xeljanz

The insurer denied the Xeljanz. The denial was reversed.

This is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.
The patient has alopecia areata and vitiligo.  There is no Food and Drug Administration (FDA) approved or plan approved therapies for alopecia areata or vitiligo. Xeljanz has been found to be effective and safe for the treatment of alopecia areata and vitiligo. The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.

"Agents which are commonly used to treat rheumatologic diseases and psoriasis are also being studied in the treatment of autoimmune diseases including vitiligo. Janus kinase (JAK) inhibitors have been evaluated in several case reports, with potential therapeutic promise thought to be related to their interference with interferon (IFN)- signaling 48, 49, 74, 75. Research has shown that IFN-induced expression of CXCL10 is critical for the progression and maintenance of depigmentation in vitiligo 76. In a recent case report, a patient with vitiligo was treated with tofacitinib, an oral JAK 1/3 inhibitor, for 5 months, and had significant repigmentation with no significant adverse effects 74." (Manga, P., Elbuluk, N., & Orlow, S. J., 2016).

Based on the above, the medical necessity for Xeljanz is substantiated.  The insurer's denial is reversed.

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


Answer: The patient is a male who presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid, cocaine, and cannabis class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to two pints of liquor and 12 beers. He had multiple prior substance use disorder treatments including an interval of sobriety for two years while in a healthy relationship with family and while participating in treatment. However, he reported up to 100 previous detoxification treatments and 5 previous rehabilitation substance use disorder treatment episodes with more recent treatments.

Answer: The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and prn medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished over the first four days of admission. He was socially withdrawn but participating in counseling and educational sessions. From the next day forward, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.

Answer: Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge.

Answer: the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.

Context:
The patient is a male who presented with a request for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid, cocaine, and cannabis class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to two pints of liquor and 12 beers. He had multiple prior substance use disorder treatments including an interval of sobriety for two years while in a healthy relationship with family and while participating in treatment. However, he reported up to 100 previous detoxification treatments and 5 previous rehabilitation substance use disorder treatment episodes with more recent treatments.

The patient was admitted for inpatient treatment with detoxification protocol. He received tapering dosages of Librium and replacement of vitamins with the availability of nicotine replacement and smoking cessation counseling and comfort medications and prn medications prescribed for pain, anxiety, and insomnia. The patient's hospital course progressed without incident. Vital signs remained normal, and the patient reported mild tremor, anxiety, restlessness and insomnia with persistently mild symptoms of withdrawal that diminished over the first four days of admission. He was socially withdrawn but participating in counseling and educational sessions. From the next day forward, the patient was participating more readily in group, educational and counseling sessions, and was receiving individual counseling with case management to enhance motivation to proceed to rehabilitation treatment.

Arrangements were being made for a direct referral to rehabilitation substance use disorder treatment which was achieved at the time of discharge. Again, the patient received active treatment together with monitoring that had occurred without incident while receiving a detoxication protocol with Librium and vitamin replacement therapy, and the patient attended groups sessions and received counseling with recommendations and planning for clinically appropriate aftercare.

The health plan denied the last day of the admission as not medically necessary. The health plan's determination is overturned.

The requested benefit of continued inpatient detoxification treatment and withdrawal management and monitoring and other medical services for the last day of service could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with multiple other substances of abuse that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. The continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services. And it was in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of American Society of Addiction Medicine (ASAM) Criteria and application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.

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


Answer: This case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.

Answer: Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.

Answer: Treatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)

Answer: The insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant).

Context:
Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.

Treatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)

The insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant). The denial was upheld.

This case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.
The F2 gene is known as the coagulation factor which is associated with impaired clotting ability. The F5 gene is also known as coagulation factor V, and is associated with coagulation factors essential for proper blood clot formation. According to current peer-reviewed literature, the testing for hypercoagulable disorders in a patient with a diagnosis of venous thromboembolism is not warranted. This is because the identification of an inheritable defect does not alter therapeutic or prophylactic anticoagulation management, and consequently it has not been associated with improved outcomes.

Based on the above, the medical necessity for genetic testing for CPT code 81241 (F5 coagulation Factor V gene analysis, Leiden variant) and 81240 (F2 gene analysis 20210G>A variant) is not substantiated.  The insurer's denial is upheld.

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


Answer: The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale.

Context:
The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was evaluated by psychiatry and one-to-one sitter for safety was ordered; he was restarted on his psychiatric medications. He was also followed by endocrinology and insulin regimen was adjusted for better diabetes management. He remained clinically stable during his hospitalization, pending possible transfer to inpatient psych facility, however, after further evaluation by psychiatry, he was considered stable from psychiatry standpoint to be discharged home. Based on the available clinical information, and patient's presentation and plan of care, the patient required hospitalization for further monitoring and evaluation of his clinical condition, however, the services could have been provided at a lower level of care.

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


Answer:
This is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.
The documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department.

Answer: Diagnosis: Angioedema

Answer: Treatment: Inpatient Admission

Answer: The insurer denied Inpatient Admission.

Context:
Diagnosis: Angioedema

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.

This is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.
The documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department. There was no indication that the patient had an allergic reaction with severe symptoms not responsive to emergency or observational care treatment such as airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability.

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

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


Answer: The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a "pins and needles", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital

Context: The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a "pins and needles", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital the health plans determination is upheld in whole. The admission for a lower level of care and with a workup was appropriate, since the admitting diagnosis in the emergency department was transient ischemic attack (TIA). The workup of the TIA does not usually require admission at the acute inpatient level of care, since the patient was hemodynamically stable, had no progression of the neurological deficits during the hospital stay, did not require administration of parenteral anticoagulants or antiplatelet agents, and had no additional medical conditions that would justify medical necessity for the admission at acute inpatient level of care.

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


Answer: The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time.

Context:
The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient appeared to be improving and the listed reason for requiring an inpatient level of care was episodic hypoxemia. However, this documented hypoxemia into the 80's was short lasting and appears to have been precipitated from a decrease in her oxygen to 2 lpm (liters per minute) from her baseline requirement of 3 lpm. This appears to have resolved by later the same day on the documents that were provided. This patient could have been cared for at a lower level of care.

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


Answer: The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary.

Answer: The patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week.

Answer: The patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls.

Answer: It is noted on 2 separate UAS that the patient requires help with the services

Context:
The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary. The health plan's determination is upheld.

The patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week.

The patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls. Typically, aide services are medically necessary for help with the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It is noted on 2 separate UAS that the patient requires help with the services however the services that would be considered medically necessary can be performed during the approved time period. There are no additional services that are noted that would require additional personal-care aide hours. Personal-care aide hours without performance of ADLs or IADLs are typically not considered medically necessary. For example monitoring for supervision or to prevent wandering is not necessarily considered an ADL or IADL. In order for an aide to be present during additional time additional level 1 or level 2 services need to be performed, however this is not the case.

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


Answer:
Hyperbilirubinemia
Inpatient stay

Answer:
The patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.
Patient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl.

Context:
Hyperbilirubinemia
Inpatient stay

The patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.
Patient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl. The health plan's determination of medical necessity is overturned in whole. This is a young infant who presented with significantly elevated indirect bilirubin levels. This was likely related to breast-feeding jaundice and inadequate intake, as well as bruising from birth which increases the amount of bilirubin present. The patient required prompt initiation of phototherapy with ongoing monitoring and intravenous fluids to ensure that the levels came down quickly. This is necessary to protect the central nervous system from bilirubin crossing the blood-brain barrier.
For well infants greater than 38 weeks gestational age, phototherapy needs to be started when values are greater than 18 mg/dL for infants greater than 72 hours of age. In fact, exchange transfusion is required for infants at that age who have bilirubin levels greater than 24 mg/dL. This is due to the risk of neurotoxicity when bilirubin values exceed the infant's capability of albumin binding to bilirubin to prevent crossing through the blood-brain barrier. This infant exceeded the risk value of total serum bilirubin and required immediate initiation of phototherapy and treatment to mitigate the risk of neurologic injury.

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


Answer:
Diagnosis: Overbite
Treatment: Braces

Answer: The patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues.

Answer: The patient also has very prominent upper anterior teeth.

Context:
Diagnosis: Overbite
Treatment: Braces
The braces are medically necessary.

The patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues. This is an "automatic qualifying" condition according to the handicapping index. The patient also has very prominent upper anterior teeth. Due to their forward position, they will be more prone to trauma over time. Orthodontic treatment is needed to correctly move her teeth into a more protective position. Both of these conditions are a reason for there to have medical necessity for orthodontic benefits.

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


Answer: The insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week.

Answer: This is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.

Answer: In early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver.

Answer: The insurer approved PCA services for 8 hours per day, 7 days per week.

Context:
Diagnosis: Dementia
Treatment: PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week

The insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week. The denial was reversed.

This is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.

In early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver.

The insurer approved PCA services for 8 hours per day, 7 days per week.  It is apparent that the patient needs caregiver assistance beyond 8 hours per day.  It is unrealistic to consider that the patient only needs to use the toilet or has incontinence episodes during 8 hours per day.  If the aide leaves after 8 hours, then either the patient is already in bed for the night, which means she is in bed for 16 hours per day; or she is still out of bed and the family needs to assist with change of clothes, toileting needs, placement in bed, and possibly dinner if the aide leaves before dinner time.

Based on the above, the medical necessity for an increase in Personal Care Aide (PCA) Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week is substantiated. The insurer's denial is reversed.

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


Answer: The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months.

Context: The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the patient's malocclusion would score a 14. The patient does not have any auto qualifiers present which include deep impinging overbite, anterior crossbite, overjet 9mm or greater, negative overjet of 3.5mm or greater, or impacted incisors or canines. The HP determination is upheld in whole.

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


Answer:
Diagnosis:  Overbite
Treatment:  Braces

Answer: The patient has a deep impinging overbite with trauma to the palatal tissues.

Context:
Diagnosis:  Overbite
Treatment:  Braces
The braces are medically necessary.

The patient has a deep impinging overbite with trauma to the palatal tissues.  This is an "automatic qualifying" condition for orthodontic benefits.

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


Answer: The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months.

Context:
The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months.
The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifier present. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5 mm or greater. Since the HLD score is less than 26 without an auto qualifier, braces are not medically necessary for this patient.

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


Answer:
Diagnosis: Open bite
Issue under review: Braces

Context:
Diagnosis: Open bite
Issue under review: Braces

Determination:
The Braces are not medically necessary.

Based upon the records presented, there is no evidence of an anterior open bite. The handicapping index was below 25, therefore the criteria for benefits has not been established. There is no medical necessity in this case.

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


Answer: This is a young female patient who presented to her orthodontist for a consult for orthodontic treatment.

Answer: The orthodontist has completed the HLD index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 22 points on the HLD index.

Answer:
Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding Bimaxillary Protrusion, Overjet and Lip Incompetence "CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip Entrapment, Convex, Lip Incompetence, and Mentalis Strain."
Treatment: Orthodontic Treatment

Answer: The insurer denied the Orthodontic Treatment.

Context:
Diagnosis: Skeletal Class I Malocclusion, Anterior Crowding Bimaxillary Protrusion, Overjet and Lip Incompetence "CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip Entrapment, Convex, Lip Incompetence, and Mentalis Strain."
Treatment: Orthodontic Treatment

The insurer denied the Orthodontic Treatment. The denial was reversed.

This is a young female patient who presented to her orthodontist for a consult for orthodontic treatment.  Per Orthodontic the patient had skeletal Class I malocclusion, anterior crowding bimaxillary protrusion, overjet and lip incompetence "CI. I Molar, CI. I Canine, Bimaxillary Alveolar Protrusion, OJ: 6mm, OB: 5mm, Lip entrapment, Convex, Lip incompetence, and Mentalis strain."  A total score of 31 was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.

The orthodontist has completed the HLD index attaining 31 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 22 points on the HLD index. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The carrier's denial of coverage for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is reversed.  The medical necessity is substantiated.

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


Answer:
Diagnosis: Abdominal Pain
Treatment: Inpatient admission

Answer:
The patient is a female who presented to the ER for further evaluation/management of left upper quadrant abdominal pain.
The patient's intake vitals were afebrile, hemodynamically stable.

Answer: Examination was non focal with no critical abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing was also without critical abnormalities noted, including no evidence of acute end organ damage. Abdominal CT revealed evidence of splanchnic portal vein thrombosis.

Answer: The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN (as needed) analgesics and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition.

Answer: The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN analgesics and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition.

Context:
Diagnosis: Abdominal Pain
Treatment: Inpatient admission

Summary:
The patient is a female who presented to the ER for further evaluation/management of left upper quadrant abdominal pain.
The patient's intake vitals were afebrile, hemodynamically stable.

Examination was non focal with no critical abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG (electrocardiogram) testing was also without critical abnormalities noted, including no evidence of acute end organ damage. Abdominal CT revealed evidence of splanchnic portal vein thrombosis.

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN (as needed) analgesics and continued cardiac monitoring. She responded well to the prescribed therapies, and she was subsequently discharged in stable condition.

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where she received treatment with therapeutic anticoagulation and supportive care with IV fluids, PRN analgesics and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition.

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

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


Answer: According to the records, the patient who initially began physical therapy for impairments and functional deficits related muscle weakness. There is a letter of appeal from the patient stating that she disagrees that physical therapy is not medically necessary, stating that it is necessary for her ability to walk without falling which involves continued work with balance and strengthening of her lower body. She reports having had two recent falls which led her and her physical therapist to believe that she needed continued work with balance and strengthening, particularly of the left leg on which she has had two surgeries, hip replacement surgery, and a knee replacement surgery. It was noted that 17 visits were authorized over six weeks. The patient is requesting coverage for continued skilled physical therapy visits, which was denied by the insurance carrier

Answer: Diagnosis is noted to be M62.81 muscle weakness, generalized, that reportedly began a year prior. It is noted that the patient was previously authorized for 17 visits of physical therapy over six weeks.

Context: According to the records, the patient who initially began physical therapy for impairments and functional deficits related muscle weakness. There is a letter of appeal from the patient stating that she disagrees that physical therapy is not medically necessary, stating that it is necessary for her ability to walk without falling which involves continued work with balance and strengthening of her lower body. She reports having had two recent falls which led her and her physical therapist to believe that she needed continued work with balance and strengthening, particularly of the left leg on which she has had two surgeries, hip replacement surgery, and a knee replacement surgery. It was noted that 17 visits were authorized over six weeks. The patient is requesting coverage for continued skilled physical therapy visits, which was denied by the insurance carrier and is the subject of this review. The health plan's determination of medical necessity is upheld. The requested health service/treatment of physical therapy is not medically necessary for this patient. Diagnosis is noted to be M62.81 muscle weakness, generalized, that reportedly began a year prior. It is noted that the patient was previously authorized for 17 visits of physical therapy over six weeks. The records provided failed to document any significant ongoing functional progress or objective gains to suggest the patient would require additional physical therapy. It appears the patient had plateaued in treatment. Although the patient reports on appeal that she needed to continue working with balance and strengthening of her lower body, this can be accomplished outside of an office setting, for further progress independently and does not require ongoing skilled therapy sessions. Medical necessity was not established.

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


Answer: The patient is a male with a history of hypertension and hyperlipidemia. In 2019 he was evaluated by a cardiologist for a complaint dyspnea with bending over. Coronary computed tomography (CT) angiography performed showed significant two vessel disease. He presented to the hospital for scheduled cardiac catheterization. His cardiovascular exam was unremarkable. There were no acute electrocardiographic changes. Catheterization was performed and an obstruction in the proximal left anterior descending coronary artery was treated with atherectomy and two stents. There was residual disease in the distal right coronary artery. The procedure was uncomplicated. He was discharged home the following day.

Context:
The patient is a male with a history of hypertension and hyperlipidemia. In 2019 he was evaluated by a cardiologist for a complaint dyspnea with bending over. Coronary computed tomography (CT) angiography performed showed significant two vessel disease. He presented to the hospital for scheduled cardiac catheterization. His cardiovascular exam was unremarkable. There were no acute electrocardiographic changes. Catheterization was performed and an obstruction in the proximal left anterior descending coronary artery was treated with atherectomy and two stents. There was residual disease in the distal right coronary artery. The procedure was uncomplicated. He was discharged home the following day.

The health plan's determination is upheld.

While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Given that atherectomy was performed and two stents were placed in the same vessel, the patient could have been appropriately managed at a lower level of care status.

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


Answer: The patient has recurrent syncope. An ambulatory monitor documented a 21 second pause. The patient

Answer: needed a permanent pacemaker in view of the recurrent syncope related to sinus pauses. The provider is requesting a leadless pacemaker

Context:
The patient has recurrent syncope. An ambulatory monitor documented a 21 second pause. The patient clearly needed a permanent pacemaker in view of the recurrent syncope related to sinus pauses. The provider is requesting a leadless pacemaker as it has shown a reduction in morbidity relative to a pacemaker with intracardiac leads. This is the subject of this review.

The health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is young and one can anticipate multiple generator changes and potential lead changes in view of the possibility of the long expected usage based on her young age. The leadless pacemaker has been approved by FDA. In this young patient with expected usage of at least 30-40 years, a leadless pacemaker is likely to be more beneficial than standard treatment. The medical literature supports its use in cases such as the present one.

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


Answer: The patient has history of (h/o) a prolonged symptomatic sinus pause for which a pacemaker was required. Under review is the Transcatheter Insertion or Replacement of Permanent Leadless Pacemaker, Right Ventricular, Including Imaging Guidance and Device Evaluation.

Context:
The patient has history of (h/o) a prolonged symptomatic sinus pause for which a pacemaker was required. Under review is the Transcatheter Insertion or Replacement of Permanent Leadless Pacemaker, Right Ventricular, Including Imaging Guidance and Device Evaluation.

The health plan's determination is upheld. A leadless pacemaker has been developed to potentially decrease pocket and lead complications and malfunctions known to occur with current implanted pacemakers. However, they do not have demonstrated long term effectiveness or demonstrated improved outcomes compared to implantable pacemakers. Therefore, they have not been established as standard of care, compared to an implanted pacemaker, towards improved cardiac outcomes. As such it is not indicated in this case.

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


Answer: The patient presented for evaluation of syncope. The patient had a history of bipolar disorder and vasovagal syncope, with episodes occurring over about 10 years and reported episodes of syncope increasing in frequency, to about once or twice a month. An electroencephalogram (EEG) was normal. An event monitor recorded a 21 second pause, with syncope correlating with this finding. An echocardiogram (ECHO) showed normal left ventricular function. Placement of a leadless pacemaker was recommended.

Context:
The patient presented for evaluation of syncope. The patient had a history of bipolar disorder and vasovagal syncope, with episodes occurring over about 10 years and reported episodes of syncope increasing in frequency, to about once or twice a month. An electroencephalogram (EEG) was normal. An event monitor recorded a 21 second pause, with syncope correlating with this finding. An echocardiogram (ECHO) showed normal left ventricular function. Placement of a leadless pacemaker was recommended. This is the subject of this review.

The health plan's determination is overturned. The leadless pacemaker is likely to be more beneficial than standard treatment for this patient. The patient has vasovagal syncope, with prolonged sinus pauses on event monitoring. She requires pacing, but does not need atrial pacing for effective therapy. The leadless pacemaker is an Food and Drug Administration (FDA) approved therapy. Per guidelines, it is acceptable to use for patients who have sinus node dysfunction, including sinus pauses, for whom atrial pacing is not considered necessary. In this patient, an additional advantage would be avoidance of long-term lead complications (fractures, infection, etc).

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


Answer: The patient is a female with a history of diabetes, chronic obstructive pulmonary disease (COPD), depression, and anxiety who presented to the hospital with hematuria. She stated that she was had recently started seeing blood in her urine or vagina that morning. She also reported suprapubic pain. She denied fevers, chills, and increased urinary frequency. She did report multiple prior urinary tract infections. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed temperature 36.5 Celsius, heart rate 71, blood pressure 137/81, and respiratory rate 15. On physical examination, she was alert, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) count of 17.5, hemoglobin 13.6, platelets 266, sodium 143, potassium 4.8, creatinine 1.47, and glucose 112. The patient was admitted with hematuria and suspected urinary tract infection. The plan of care included urine culture, intravenous (IV) antibiotics, kidney ultrasound, monitor kidney function, IV fluids, and continue other home medications. The patient was later diagnosed with Clostridium (C.) difficile (diff) after developing diarrhea. She requested to be discharged against medical advice.

Context:
The patient is a female with a history of diabetes, chronic obstructive pulmonary disease (COPD), depression, and anxiety who presented to the hospital with hematuria. She stated that she was had recently started seeing blood in her urine or vagina that morning. She also reported suprapubic pain. She denied fevers, chills, and increased urinary frequency. She did report multiple prior urinary tract infections. Review of systems was negative for fevers, chills, chest pain and shortness of breath. Vital signs showed temperature 36.5 Celsius, heart rate 71, blood pressure 137/81, and respiratory rate 15. On physical examination, she was alert, heart was regular, breath sounds were normal, abdomen was soft and nontender. Labs showed white blood cell (WBC) count of 17.5, hemoglobin 13.6, platelets 266, sodium 143, potassium 4.8, creatinine 1.47, and glucose 112. The patient was admitted with hematuria and suspected urinary tract infection. The plan of care included urine culture, intravenous (IV) antibiotics, kidney ultrasound, monitor kidney function, IV fluids, and continue other home medications. The patient was later diagnosed with Clostridium (C.) difficile (diff) after developing diarrhea. She requested to be discharged against medical advice.

The health plan's determination is upheld.

No, the inpatient hospital stay was not medically necessary, based on the available documentation. The patient primarily was admitted for urinary tract infection in the setting of multiple urinary tract infections in the past. The patient was hemodynamically stable. She had an elevated white blood cell count, but no evidence of sepsis or pyelonephritis, she was not encephalopathic, and was only incidentally found to have C. diff infection after developing diarrhea, but this can be treated as an outpatient, especially when symptoms are mild. The patient had no other acute complications. She needed further care, but it could have been safely and effectively provided at a lower level.

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


Answer:
Diagnosis: Idiopathic focal segmental glomerulosclerosis post kidney transplant
Treatment: Velcade

Answer: This child has undergone the standard therapy for antibody mediated rejection and has had no evidence of improvement.

Answer: This child has a very high possibility of losing her graft with the levels of antibodies and specially after failing to respond to standard therapy.  Bortezomib is the last option to attempt to preserve renal function, by eliminating plasma cells that are the producers of antibodies.  This kidney graft does not have significant chronic injury.

Context:
Diagnosis: Idiopathic focal segmental glomerulosclerosis post kidney transplant
Treatment: Velcade
The treatment with Velcade is medically necessary.

In treating children with this complex rejection presentation, commitment to prolong and rescue this first kidney allograft using the therapies available to control the process and resolve if it is possible must be made.  Most of the immunosuppressive medications do not have absolute FDA indication for immunosuppression in organ transplantation.  The use of these medications is based on clinical retrospective trials, small series, and most importantly, the need to solve complex immunological phenomena by learning from other disciplines such as Pediatric Oncology and others.

Previous review labeled the use of Bortezomib as unproven, with no RCT (randomized controlled trials) for the evaluation of the efficacy of Bortezomib for the treatment of antibody mediated rejection.  This child has undergone the standard therapy for antibody mediated rejection and has had no evidence of improvement.  The use of Bortezomib for the treatment of antibody mediated rejection in children has been done and published in small series demonstrating that Bortezomib stabilizes the immunological process and may preserve renal function in the majority of children treated.

This child has a very high possibility of losing her graft with the levels of antibodies and specially after failing to respond to standard therapy.  Bortezomib is the last option to attempt to preserve renal function, by eliminating plasma cells that are the producers of antibodies.  This kidney graft does not have significant chronic injury.

In this reviewer's opinion, and supported by literature in pediatric kidney transplant patients, Bortezomib is justified for the treatment of non-responding acute antibody mediated rejection on this child's care. This child needs adequate renal function in the next years to accomplish adequate growth and development.  Graft failure and dialysis will be a devastating complication. This is a very difficult disorder in pediatric organ transplantation, lacking good agents to treat patients with high levels of antibodies injuring the graft effectively.  In patients like this, it takes a full combination of all agents available to attempt to provide control and possible resolution of this disorder.

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