Answer: The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction.

Context: The patient , who requests an increase in personal-care assistant hours from 70 hours a week to 112 hours a week. The patient has a past medical history significant for hyperlipidemia, diabetes mellitus type 2, hypertension, and cognitive dysfunction.  The health plan's determination is upheld.  The requested health service/treatment of personal care assistance increase from 70 hours per week to 112 hours per week is not medically necessary for this patient.  Additional services are not medically necessary. Typically for services to be considered medically necessary the aide must be functioning and performing ADLs and/or IADLs.  It is noted that the patient's ADLs and IADLs can be performed within the allotted time.  Services for monitoring for safety or companion care without the necessity of underlying ADLs or IADLs are not considered medically necessary.  No additional hours are medically necessary.

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


Answer: The patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation.

Answer: Diagnosis: Crohn's Disease

Answer: Treatment: Medication- Humira

Answer: The insurer denied treatment with Humira.

Context:
Diagnosis: Crohn's Disease

Treatment: Medication- Humira

The insurer denied treatment with Humira. The denial was upheld.

The patient is a child with long standing constipation, diagnosed with Crohn's disease. His Gastroenterologist is requesting authorization for Humira.  Bloodwork showed a platelet count of 662, albumin 3.0, CRP 67.6, ESR of 53. Patient underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Pathology report demonstrates chronic ileitis with granuloma, colitis. Patient was started on steroids, which improved many of his symptoms. Plain x-ray shows constipation. Recent emerging data has demonstrated disproportionate risks of hepatosplenic T-cell lymphoma among adolescent males exposed to immunomodulators.

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


Answer:
Diagnosis: SOB; Wheezing
Issue under review: Inpatient admission

Answer: The patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation.

Context:
Diagnosis: SOB; Wheezing
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient had asthma exacerbation with failed outpatient therapy, emergency room therapy. The patient had history of similar asthma exacerbations in the past with requiring mechanical ventilation. Since the patient failed outpatient as well as emergency room treatment and had significant anxiety symptoms during early hospitalization stay, the acute in hospital level of care was medically necessary.

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


Answer:
Diagnosis: Diabetes type II, status post mechanical fall
Treatment: Inpatient admission

Answer: The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes.

Answer: The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.

Answer: The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture.

Answer: Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy.

Answer: On the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care.

Answer: The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department.

Context:
Diagnosis: Diabetes type II, status post mechanical fall
Treatment: Inpatient admission
The inpatient admission as not medically necessary.

The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead.  She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes.

The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air.  On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead.  No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait.  She was awake, alert and oriented times three.  She had mild tenderness in the right knee.

The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7.  CT of the cervical spine and head demonstrated no evidence of acute pathology.  Chest x-ray showed no evidence of acute cardiopulmonary disease.  EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm.  Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion.  Impression included unspecified fall, and vertical patellar fracture.

Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room.  It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement.  Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics.  While on admission, she was seen by physical therapy.

On the day of discharge, the patient was medically stable for discharge home.   It was noted that she will receive home care.

The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead.  Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty.  She was hemodynamically stable when she presented to the emergency department.  There was no evidence of altered mental status, confusion, respiratory compromise, significant persistent life-threatening arrhythmias, or sepsis.  There were no serious neurologic abnormalities like brain infection, cerebral bleeding/ischemia, increased intracranial pressure or spinal cord injury.  CAT scan of the brain did not show any acute bleed or hemorrhage.

In view of the foregoing, the inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.

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


Answer:
Varicose veins
Surgical services

Answer: The patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein.

Context:
Varicose veins
Surgical services

The patient presented with right leg symptomatic varicose veins. Main symptoms include burning, aching and throbbing. The patient has attempted and failed conservative therapy with graded compression stockings for several months' duration. The symptoms are lifestyle limiting and interfere with  activities of daily living. A duplex scan demonstrates reflux in the right accessory great saphenous vein. The health plan's determination of medical necessity is overturned in whole. Endovenous ablation of the right accessory great saphenous vein for this patient is the current standard of care treatment for symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.

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


Answer:
Diagnosis: Oligometastatic lesion in the abdominal wall
Treatment: SBRT

Answer: In this case, the patient is a male with a history of lung cancer s/p definitive chemoradiotherapy.  The patient developed brain metastasis s/p resection.  The patient was recently found to have an oligometastatic lesion in the abdominal wall.   Local therapy to the oligometastatic abdominal wall lesion was recommended, and stereotactic body radiosurgery was requested.

Answer: This patient has an oligometastatic abdominal wall lesion with any active disease elsewhere

Context:
Diagnosis: Oligometastatic lesion in the abdominal wall
Treatment: SBRT
The SBRT is medically necessary.

Stereotactic radiosurgery (SRS) is a highly precise form of radiation therapy used primarily to treat tumors and other abnormalities of the brain. The treatment involves the delivery of a single high-dose, or sometimes smaller, multiple doses, of radiation beams that converge on the specific area where the tumor or other abnormality resides.   It is a highly precise treatment, is able to minimize the amount of radiation to surrounding healthy and critical tissues.  Extracranial stereotactic radiosurgery or stereotactic body radiotherapy (SBRT) for certain conditions has also been shown to be safe and effective as compared to the standard radiation therapy.  Some of the conditions that have shown the most potential include spinal tumors, liver tumors and inoperable stage I lung cancers.  Other conditions include re-treatment of previous treated areas where conventional radiation in is inadequate in sparing surrounding normal tissues.  SBRT is FDA-approved.  It is not subject to IRB (institutional review board) review, and its effectiveness has been proven based on clinical evidence reported in peer-reviewed medical literature.

In this case, the patient is a male with a history of lung cancer s/p definitive chemoradiotherapy.  The patient developed brain metastasis s/p resection.  The patient was recently found to have an oligometastatic lesion in the abdominal wall.   Local therapy to the oligometastatic abdominal wall lesion was recommended, and stereotactic body radiosurgery was requested.

There is clinical data demonstrating the safety and effectiveness of stereotactic radiosurgery for oligometastatic lesions.  In fact, SBRT may provide a better local control compared to standard fractionated radiation therapy.

A 2013 review article by Tree et al. evaluated studies on SBRT for oligometastatic disease.  The authors stated, "Many non-randomised studies have shown that SBRT for oligometastases is safe and effective, with local control rates of about 80%", and concluded that "SBRT offers durable local control and the potential for progression-free survival in non-liver, non-lung oligometastatic disease at a range of sites."

In addition, a 2019 multi-institution randomized trial (SABR-COMET trial) randomized 99 patients with oligometastatic lesions (1-5 lesions) into control group vs SBRT.  Median overall survival was 28 months in the control group versus 41 months in the SABR (SBRT) group (p=0090). Treatment-related deaths occurred in three (45%) of 66 patients after SABR, compared with none in the control group.  The authors concluded, "SABR (SBRT) was associated with an improvement in overall survival, meeting the primary endpoint of this trial."

This patient has an oligometastatic abdominal wall lesion with any active disease elsewhere, and if they are controlled with SBRT, the patient may have a prolonged survival.  Stereotactic radiosurgery has been shown to be safe and effective for the treatment of oligometastatic/solitary lesions, and in this case, is the best option that can help with disease control.  Stereotactic body radiotherapy (SBRT) is, therefore, considered medically necessary for this patient at this time.

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


Answer: This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations.

Context:
This is a patient with a history of substance use disorder who presented  with a request for detoxification services after relapsing. The patient was using heroin with up to 5 bags with intranasal administration on a continuous daily basis together with use of a prescribed benzodiazepine. She has a history of a mental disorder best characterized as schizophrenia treated with quetiapine, and major depressive disorder. She has a history of psychiatric hospitalizations. The health plan's determination of medical necessity is upheld.
The continued treatment could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizophrenia and ongoing substance use disorder with heroin and a prescribed benzodiazepine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or acute symptoms of psychosis, or perceptual disturbance that would have warranted inpatient level treatment for the time interval under review. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required continued withdrawal management or general medical services, as noted in the clinical summary. The patient had fair insight and control of impulses and was cooperative and generally motivated to continue with substance use disorder treatment.

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


Answer: In this case, this patient had

Answer: pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics

Answer: Diagnosis: Pneumonia and sepsis

Answer: Treatment: Inpatient admission

Answer: The insurer has denied Inpatient admission.

Answer: This patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.

Answer: The insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care.

Context:
Diagnosis: Pneumonia and sepsis

Treatment: Inpatient admission

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

This patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.

The insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care.

Chart notes provided enough specific evidence to support the patient required 24-hour hospital treatment during the period in question. The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate those patients who exhibit failure to achieve abstinence or patients who relapse frequently, or fail to be cooperative with or benefit from outpatient detoxification; currently abuse other substances, very heavy use or tolerance, putting one at high risk for complicated withdrawal; are candidates for inpatient detoxification treatment.

In this case, this patient had serious medical problems, including pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics, so he could not safely and effectively be treated for heroin detoxification in an outpatient setting. He required 24-hour medical hospital treatment then.

According to the LOCADTR, he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use heroin, alcohol, and cocaine, despite multiple serious medical issues, and he required and needed methadone for heroin detoxification. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting; including severe withdrawal symptoms. He had serious medical issues complicating treatment for heroin detoxification. Inpatient medical hospital treatment was medically necessary. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

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

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


Answer: This is a male patient who was seen in the hospital.  He had a past medical history of hypertension, hyperlipidemia, chronic kidney disease, cervical stenosis of spine and an immune disorder.  The patient was noted to have recently started dialysis.  The patient complained of progressively worsening kidney function and right knee pain.  The patient recently left earlier in the day against medical advice and came back for treatment.  The patient was evaluated by surgery to have an arteriovenous (AV) fistula placed as a better method of hemodialysis treatment.  The patient had a PermaCath placed.  He patient complained of right knee pain that comes and goes on its own, but has gotten worse in the last three to four days prior to presentation.  His pain level was a 10/10.  The patient admitted to a history of dry cough on and off.  The patient had a white blood cell count of 15.3, a red blood cell count of 3.06, a hemoglobin of 9.1, a hematocrit of 28.5%, platelets 338, a sodium of 138, a potassium of 3.6, a chloride of 100, a dioxide level of 25, a blood urea nitrogen (BUN) level of 52, a creatinine of 3.02, a glucose of 112, a calcium of 8, a phosphorus of 2, and a magnesium of 1.9.  The patient had a blood pressure of 108/70 with a pulse of 78, respirations of 18, an oxygen saturation of 98% and a temperature of 98.1.  On examination, the right knee was tender and painful, as well as warm.  The patient was having an acute gout flare.  The patient received methadone, Keppra, prednisone, Renagel, Os-Cal, and Procardia.  The patient was then discharged.

Answer: Diagnosis:  Chronic kidney disease

Answer: Treatment:  Inpatient hospital services

Answer: The insurer has denied inpatient hospital services.

Answer: The documentation indicated that the patient was seen for progressively worsening kidney function, as well as right knee pain.  The patient recently started dialysis.

Context:
Diagnosis:  Chronic kidney disease

Treatment:  Inpatient hospital services

The insurer has denied inpatient hospital services.  The denial was upheld.

This is a male patient who was seen in the hospital.  He had a past medical history of hypertension, hyperlipidemia, chronic kidney disease, cervical stenosis of spine and an immune disorder.  The patient was noted to have recently started dialysis.  The patient complained of progressively worsening kidney function and right knee pain.  The patient recently left earlier in the day against medical advice and came back for treatment.  The patient was evaluated by surgery to have an arteriovenous (AV) fistula placed as a better method of hemodialysis treatment.  The patient had a PermaCath placed.  He patient complained of right knee pain that comes and goes on its own, but has gotten worse in the last three to four days prior to presentation.  His pain level was a 10/10.  The patient admitted to a history of dry cough on and off.  The patient had a white blood cell count of 15.3, a red blood cell count of 3.06, a hemoglobin of 9.1, a hematocrit of 28.5%, platelets 338, a sodium of 138, a potassium of 3.6, a chloride of 100, a dioxide level of 25, a blood urea nitrogen (BUN) level of 52, a creatinine of 3.02, a glucose of 112, a calcium of 8, a phosphorus of 2, and a magnesium of 1.9.  The patient had a blood pressure of 108/70 with a pulse of 78, respirations of 18, an oxygen saturation of 98% and a temperature of 98.1.  On examination, the right knee was tender and painful, as well as warm.  The patient was having an acute gout flare.  The patient received methadone, Keppra, prednisone, Renagel, Os-Cal, and Procardia.  The patient was then discharged.

Analysis and Rationale:

The medical literature indicates that admission is indicated for patients with chronic renal failure if there is evidence of cardiac arrhythmias of immediate concern, recurrent seizures, encephalopathy, impaired hemostasis with active bleeding, superinfection not treatable in an outpatient setting, unexplained syncope, hemodynamic instability, uremic symptoms that are severe or persistent despite observational care treatment, significant respiratory findings that are severe or persistent despite observational care treatment, clinically significant metabolic or electrolyte abnormality that are severe or persistent despite observational care treatment, urgent treatment of renal failure necessary on an inpatient basis due to vascular access not previously established or not usable, continuous intravenous infusion of anticoagulant, vasoactive or antiarrhythmic medication needed, pulmonary artery catheter monitoring needed or temporary pacemaker placement required.

The documentation indicated that the patient was seen for progressively worsening kidney function, as well as right knee pain.  The patient recently started dialysis.  The patient had none of the above medical indications for inpatient admission to an acute care hospital.  The patient's condition was appropriate for a level of observational care rather than inpatient level of care.  As such, the inpatient hospital services at the acute level of care are not medically necessary and the prior determination is upheld.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.

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


Answer: This case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.

Answer: Diagnosis: Sickle cell crisis

Answer: Treatment: Inpatient admission, medication, monitoring

Answer: The insurer denied the inpatient admission.

Answer: He responded to pain medications.

Context:
Diagnosis: Sickle cell crisis

Treatment: Inpatient admission, medication, monitoring

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

This case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.

MCG indicates that admission for sickle cell may be appropriate for patients who have acute pulmonary symptoms, hypoxemia or acidosis, and altered mental status, respiratory treatments needed that can only be performed in an acute inpatient setting, or pain insufficiently responsive to observation care that requires treatment in inpatient setting, such as parenteral opioids.  The patient did not have hypoxemia or an altered mental status. He responded to pain medications. The records failed to support the patient could not have been treated at a lower level of care, such as observation.  The patient was not noted to have failed observation care.

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

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


Answer: Diagnosis: Septicemia

Answer: Treatment: Inpatient Admission

Answer: The insurer denied Inpatient Admission.

Answer: This is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.

Answer: According to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors.

Context:
Diagnosis: Septicemia

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was reversed.

This is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.

According to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors.

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

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


Answer: This is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.

Answer: Diagnosis: Seizure Disorder

Answer: Treatment: Inpatient Admission

Answer: The insurer denied the Inpatient Admission.

Context:
Diagnosis: Seizure Disorder

Treatment: Inpatient Admission

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

This is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.

MCG indicate that admission may be appropriate for patients who have a new onset severe neurologic finding requiring inpatient care, a neurological trauma requiring inpatient treatment, or for a neurologic condition, symptoms, or finding for which emergency and observation have failed or are not considered appropriate. Additionally, admission for seizure would be appropriate for patients who had status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder, cardiac arrhythmia of immediate concern, altered mental status that is severe or persistent, a new focal neurologic deficit, or for a recurrent seizure. The records supported that the patient had a syncopal episode, rule out seizure. The patient was admitted with the diagnosis of seizure. At the time of admission, the patient did not have focal deficits and had not failed Emergency Department care. The records failed to support that the patient had hemodynamic instability, status epilepticus, repetitive seizures or recurrent seizures.  The records failed to support that the patient could not have been placed at a lower level of care, such as observation.

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

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


Answer:
Diagnosis: Possible Sepsis/Pneumonia/Bronchitis

Treatment: Inpatient admission

The insurer denied inpatient admission.

Answer: This is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.

Answer: At presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.

Answer: The patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.

Answer: She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.

Answer: The patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.

Answer: The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.

Answer: The patient was tolerating oral intake

Context:
Diagnosis: Possible Sepsis/Pneumonia/Bronchitis

Treatment: Inpatient admission

The insurer denied inpatient admission. The denial was upheld.

This is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.

At presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.

The patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.  As per the history & physical, the patient was in no acute distress.  She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.

The patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.  There were no signs of sepsis.  The patient did not need acute hospitalization.  She could have been placed under observation status while diagnostic testing and treatment were initiated.  The patient was tolerating oral intake and could have been switched to oral antibiotics and discharged home with close follow-up in an outpatient setting.  The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.

The prior denial is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

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


Answer: This is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy.

Context:
Reviewer # 3:

This is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy.

The test is recommended for the member in expert guidelines and is the most appropriate test in these circumstances, and is shown to improve the rate of success for pregnancies in these circumstances and it also helps prevent pregnancies with aneuploidy.

According to Vitez, S. F., et al. (2019), "Miscarriage is a frequent outcome seen in obstetrics with 1 in 5 pregnancies ending in an early pregnancy loss.  Aneuploidy is the most significant single factor affecting early pregnancy failure and miscarriage.  The risk of aneuploidy increases significantly with increasing maternal age.  There has been tremendous advancement in technology that has made preimplantation genetic testing for aneuploidy reliable and accessible.  For women in their mid-to-late 30s there is great utility in the use of PGT-A to facilitate single embryo transfer, reduce the risk of clinical miscarriage and ongoing aneuploidy gestations.  The current data supports use of preimplantation genetic testing for aneuploidy and single embryo transfer for this population of women."

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed, as this procedure is likely to be more beneficial than any of the standard testing / procedures.

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


Answer: This is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.

Answer: The patient

Answer: is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age.

Context:
Reviewer # 2:
This is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.

According to Capalbo, A., et al. (2016) states, "Blastocyst biopsy is now widely used for both preimplantation genetic screening (PGS) for aneuploidies and preimplantation genetic diagnosis (PGD) of single gene defects.  In particular, trophectoderm biopsy coupled with comprehensive chromosome screening (CCS) now represents the most promising approach for PGS to detect aneuploidies coming from both male and female meiosis, as well as clinically relevant mitotic errors fixed during preimplantation embryo development."

The patient is a good candidate for this procedure because she is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age.

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed.

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


Answer: This is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.

Answer: Diagnosis: IVF with preimplantation genetic screening.

Answer: Treatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.

Answer: The insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.

Context:
Diagnosis: IVF with preimplantation genetic screening.

Treatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.

The insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos. The denial was reversed.

Reviewer #1:

This is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.
American Society of Reproductive Medicine (ASRM) also stated the following:" A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age."

At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent.

This patient is not a good candidate for the procedure, as the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos does not have final approval from the appropriate regulatory bodies for this diagnosis.
The requested service is not the best available treatment for this patient at this time, and is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be upheld.

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


Answer:
Diagnosis: Back pain
Issue under review: Intracept procedure

Context:
Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should not cover the intracept procedure.

The health plan should not cover the proposed treatment based on general standard of care for vertebrogenic pain, and based on the patient not meeting the following recommended requirements by RELIEVANT, the Intracept Medical device manufacturer (source: https://www.relievant.com/wp-content/uploads/2019/05/MKT_0066-RevD_-_Reimbursement_Guide.pdf):

 Intracept is medically indicated in patients who have
- A history of low back pain of at least 6 months duration; and
- Failed to respond to at least 6 months of non-surgical management; and - MRI demonstrated Modic Type 1 or Type 2 changes* at one or more vertebrae from L3 to S1; and
- Activities of daily living that are limited by persistent low back pain; and
- All other reasonable sources of pain have been ruled out.

The above-recommended requirements have not been met for the INTRACEPT procedure, because despite history of chronic low back pain of more than six months, the MRI findings did not point to any evidence of Modic type 1 or type 2  changes at any vertebra. There is also no documented evidence of limitation of ADLs (activities of daily living) by the patient, and that all other reasonable sources of the chronic low back pain have been ruled out.

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


Answer:
Diagnosis: Back pain
Issue under review: Intracept Procedure

Context:
Diagnosis: Back pain
Issue under review: Intracept Procedure

Determination:
The health plan should cover the Intracept procedure.

Although intraosseus radiofrequency treatment of the basivertebral nerve (Intracept procedure) is a relatively new treatment for low back pain with Modic endplate changes, there is adequate evidence from randomized controlled trials, cited below, including a multi-center trial, to substantiate its effectiveness.  The patient's symptoms and the MRI evidence of Modic endplate changes confirm that the patient suffers from the type of back pain that has been shown to benefit from this treatment.

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


Answer:
Diagnosis: Back pain
Issue under review: Intracept procedure

Answer: The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications.

Context:
Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should cover the Intracept procedure.

The requested procedure is a new, albeit FDA-approved procedure with this patient's indication in mind. There are RCT (randomized controlled trials) that show its effectiveness at two years.  In fact, there is another follow-up study where it was recommended that patients cross over to the treatment arm due to effectiveness early on.  The indication is for back pain that is thought to be originating from endplate degeneration (modic changes), which is what is shown in this patient. The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications.

Given that the alternative options (lumbar fusion), have not shown to have favorable responses for axial low back pain in the literature and is much more invasive, the requested Intracept procedure should be approved.

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


Answer: This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation.

Answer: The insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week).

Answer: This patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.

Answer: the patient would not be able to effectively manage having a meal, snack or fluids when she is alone.

Answer: The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System.

Answer: The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved).

Context:
This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation.

The insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week). The denial was reversed.

This patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.  Therefore, the patient would not be able to effectively manage having a meal, snack or fluids when she is alone. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary.  The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System. The patient needs a caregiver (paid or voluntary) present in her home to provide assistance with ADLs (including toileting, incontinence care, transfers, locomotion, bed mobility) during the day and night as a result of her functional impairments associated with multiple medical conditions. The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved).  It is reasonable to conclude that he cannot provide care on a consistent basis for 10 hours per day. Therefore, it is medically necessary for PCA services to provide the assistance the patient requires during those 10 hours.

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


Answer: The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.

Answer: This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management.

Context: The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.  The health plan's determination is overturned.  This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management.  She required overnight hospitalization for continued IVF hydration to ensure safe discharge.

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


Answer: The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary.

Answer: She is able to ambulate, toilet, and eat independently.

Context: The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary. The health plan's determination is upheld. The personal care hours are not medically necessary. The patient can perform many of the tasks independently - at least 50% of the task. She is able to ambulate, toilet, and eat independently. There are no noted additional services that were noted to be medically necessary.

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


Answer: This is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.

Answer: Diagnosis: Prostate Cancer

Answer: Treatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)

Answer: The insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815).

Answer: The patient's PSA had shown an increase over several years.

Answer: In this case

Answer: the patient had radiation therapy after the negative PET Scan.

Context:
Diagnosis: Prostate Cancer

Treatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)

The insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815). The denial was upheld.

This is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.

Axumin PET scans were FDA approved in 2016 for biochemical recurrence of prostate cancer, namely a rising PSA noted after definitive local therapy, such as radical prostatectomy or radiation therapy. FDA approval of Axumin included a trial showing it to perform as well, if not better, than C11 Choline scans in patients with median PSA value of 1.44. The optimal utilization of Axumin PET scans has yet to be fully delineated by NCCN or American Urological Association (AUA) guidelines. NCCN also notes it is unclear what to do when such imaging is positive in setting of negative conventional imaging. However, imaging with this modality is felt to be most useful early in the course of a suspected biochemical recurrence.

The patient's PSA had shown an increase over several years. In any event, in the setting of BCR (biochemical recurrence) for previously treated prostate cancer, CT scan and bone scan remain first line imaging, despite their limitations in limited volume disease recurrence. As noted, the role of Axumin PET remains unclear. In this case, in fact, the patient had radiation therapy after the negative PET Scan. This is consistent with the lack of clarity of how this test affects therapy in setting of suspected recurrence.

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

The carrier's denial of coverage for the Positron Emission Tomography (PET) scan skull base to mid-thigh (78815) performed is upheld. The medical necessity is not substantiated.

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


Answer:
Diagnosis:  Substance abuse
Treatment:  Inpatient rehabilitation

Answer: The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues

Context:
Diagnosis:  Substance abuse
Treatment:  Inpatient rehabilitation
The inpatient rehabilitation substance use disorder treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring.  The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts.  Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review.  The patient had presented with a level of stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care.  He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment.  He readily engaged with treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living.  Thus, the health plan's determination is reasonable in this case scenario.  This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.

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


Answer: The patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.

Answer: The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis

Answer: gastroenteritis and/or colitis may have been present

Answer: She was

Answer: treated with intravenous fluids and antibiotics.

Answer:
Abdominal pain
Inpatient hospital

Context:
Abdominal pain
Inpatient hospital

The patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis but was not consistent with pathology such as gastrointestinal perforation, pancreatitis, abscess, toxic megacolon, or bowel obstruction. Although uncomplicated gastroenteritis and/or colitis may have been present, the patient did not have peritonitis, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care. She was appropriately treated with intravenous fluids and antibiotics. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, intravenous fluid administration, and sitter monitoring could have been performed at a lower level of care.

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


Answer:
Diagnosis: Dental-deep impinging overbite
Treatment: Dental/Orthodontic Procedure

Answer: This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.

Answer: The insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary.

Answer: the patient exhibits a significant malocclusion.

Answer: In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite.

Context:
Diagnosis: Dental-deep impinging overbite
Treatment: Dental/Orthodontic Procedure

Summary: This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.

The insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary. The denial was reversed.

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 Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the 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 deep impinging overbite. 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.

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


Answer:
Diagnosis: pain
Issue under review: inpatient admission

Answer: The patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day.

Context:
Diagnosis: pain
Issue under review: inpatient admission

Determination:
Inpatient admission was not medically necessary.

The patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day. Since she had no evidence of infection, dehydration bowel obstruction, peritonitis, and did not need any surgical or endoscopic intervention, and she felt better within 24 hours of hydration and pain management, she could have been safely managed at the lower level of care.

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


Answer:
Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Answer: This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.

Answer: The insurer has denied coverage for the inpatient hospital admission as not medically necessary.

Answer: As per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air.

Answer: He was speaking in full sentences.

Answer: Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use.

Context:
Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

As per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air. The patient was in no apparent distress. He was speaking in full sentences. No use of accessory muscles was noted. Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use. Based on review of the medical record, acute hospitalization was not medically necessary. The patient could have been placed in observation status. He was improving after treatment in ED. He was afebrile and hemodynamically stable as per history and physical. He was not hypoxic. Chest x-ray showed no infiltrate. This patient could have been treated with IV steroids, bronchodilators and inhaled corticosteroid combination inhalers and long acting beta agonist inhalers while under observation. The patient remained stable overnight and was discharged the next day. He could have been placed on observation status while diagnostic testing and treatment was initiated.

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


Answer:
Diagnosis: CAD
Issue under review: Inpatient admission

Answer: This was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy.

Answer: his CXR was negative

Answer: the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler.

Answer: The patient was admitted for monitoring

Context:
Diagnosis: CAD
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This was an elective, scheduled, uncomplicated percutaneous intervention on a patient with known anatomy. Both guidelines and standard community practice would recommend that it is safely performed in an outpatient setting. In this case, there was never any hemodynamic instability, angina, ischemic changes, or an unstable situation. While the patient did complain of a brief episode of dyspnea, his CXR was negative, his ABG was normal, O2 saturation was 98%. The only treatment that was recommended was an inhaler.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care post-PCI that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of ischemia post procedure.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. The procedure was electively scheduled and performed without complication, and the recovery essentially uneventful. The patient's SOB was brief, reversible and did not require significant intervention. There was no requirement in any part of this admission that required acute level of care.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome) present. Neither triple vessel CAD nor being a smoker requires an inpatient level of care. There was no evidence of "inadequate physiologic recovery." There is no evidence to support that the patient's potential for a complication required an inpatient level of care. Since all testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care, the inpatient level of care was thus not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

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


Answer: The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra.

Context:
The patient is a male with systemic juvenile idiopathic arthritis who is prescribed Kineret. The health plan denied it as not medically necessary as he did not try the preferred medications, Ilaris and Actemra. The health plan's determination is overturned.  The Kineret is medically necessary for the patient.

Anakinra, along with Ilaris and Actemra are considered standard of care treatments for SJIA however, the American College of Rheumatology, in its most recent guidelines, recommends anakinra as initial therapy or for continued disease activity following NSAIDs as in this patient's case.

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


Answer: Diagnosis: Suicide attempt, hallucinations.

Answer: Treatment: Inpatient admission, evaluation, and medication management

Answer: The insurer has denied inpatient mental health.

Answer: The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.

Answer: The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.

Context:
Diagnosis: Suicide attempt, hallucinations.

Treatment: Inpatient admission, evaluation, and medication management

The insurer has denied inpatient mental health. That denial was modified.

The patient was admitted to inpatient mental health treatment due to a suicide attempt by overdose of Mirtazapine. She had reports of command auditory hallucinations suicidal in nature, persecutory delusional thinking, depressed mood, feelings of hopelessness, helplessness, and worthlessness, psychomotor retardation, irritable mood, poor activities of daily living (ADLs), and she had a past reported suicide attempt. She was initially admitted to telemetry after the suicide attempt.  She had diagnoses of Schizoaffective Disorder and Major Depressive Disorder.  She took Abilify.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary.  They stated that she was stable with no self-harm or suicidal thoughts, had no mention of active psychiatric issues, was responsive to treatment, and they recommended a less restrictive level of care.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and past suicide attempts are the single most reliable indicator of suicide.  It also states that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital.  This patient was considered a high risk patient and required continued inpatient acute hospital treatment in the hospital as she had three reported suicide attempts in 2018 and was considered a high risk for suicide.  She also continued with psychotic and depressive symptoms during part of the denial period.

The documentation supports the need for approval in part.

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


Answer:
Diagnosis: Benign prostatic hyperplasia
Treatment: Acute Inpatient Hospital Admission

Context:
Diagnosis: Benign prostatic hyperplasia
Treatment: Acute Inpatient Hospital Admission

Summary:
Care after an uncomplicated TURP can be provided at a lower level of care.  Because there were no signs of complications, infection, excessive bleeding, or instability an acute inpatient level of care was not necessary.  The care of his co-morbid conditions was routine.  An observation level of care was appropriate

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


Answer:
Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)
Treatment:  Surgical Services (Stomach surgery for weight loss)

Answer: The insurer has denied coverage for stomach surgery for weight loss.

Answer: This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.

Answer: At the most recent visit, the patient had a BMI of 39.2

Answer: her HbA1C is

Answer: 6.2, which is considered pre-diabetic.

Context:
Diagnosis: Endocrine/Metabolic/Nutritional (Morbid obesity), Digestive System/ Gastrointestinal (GERD), Respiratory System (Sleep apnea)
Treatment:  Surgical Services (Stomach surgery for weight loss)

Summary: This patient has a history of morbid obesity, migraine, asthma, gastroesophageal reflux disease (GERD) without esophagitis, sleep apnea, and diabetes mellitus. Per the office note with the Bariatric Surgeon, the patient has completed all preop evaluation for bariatric surgery and is ready to proceed. The patient's body mass index (BMI) was 38.8. Per the note for the initial bariatric evaluation, the patient had a BMI of 38 and had diabetes diagnosed two to three years ago. She has had numerous weight loss attempts. The Pulmonologist/ Sleep Medicine specialist noted in a letter that the patient has morbid obesity and symptoms suggestive of obstructive sleep apnea (OSA). Her exam is significant for morbid obesity and a crowded oropharynx. The Home Sleep Apnea Testing (HSAT) showed mild OSA with an apnea hypopnea index (AHI) of 7/hr. She was not contraindicated for surgery, although deep extubation should be avoided and anesthesia consultation prior to surgery should be done. The Dietitian saw the patient for nutrition consultation and found that the patient has made significant attempts at non-surgical weight loss using a variety of methods. The patient was counseled regarding preop diet, as well as the progression of food after surgery. It was noted that the patient is required to follow up with the dietician or nutritionist both pre and post-surgery for further dietary guidance and behavioral change counseling, and it was also recommended that the patient attend support groups and educational workshops when available. Labs showed that the HbA1c was 6.2, which is considered pre diabetic. The patient was seen by the Cardiologist for preop evaluation for coronary artery disease (CAD) and was found to have no contraindication for surgery.

The insurer has denied coverage for stomach surgery for weight loss. The denial was upheld.

Based upon the records provided, the patient does not meet the criteria and indications for bariatric surgery. At the most recent visit, the patient had a BMI of 39.2 and has never had a BMI greater than 40. She does not have severe sleep apnea/OSA but rather very mild OSA with an AHI of only 7/hour. In fact, the Pulmonologist did not confirm that she had sleep apnea, but only that she has symptoms that are suggestive of OSA and an exam significant for a crowded oropharynx. She does not have diabetes as her HbA1C is only 6.2, which is considered pre-diabetic. Although she has undergone appropriate evaluation including psychiatric and nutrition, and has followed a medically supervised program, she does not meet the BMI criteria and she does not have significant co-morbidities. The medical necessity is not substantiated.

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


Answer:
Diagnosis: Attention and concentration deficit; major depressive disorder
Treatment: Methylphenidate HCI 5MG

Answer: The patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam.

Answer: The patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.

Answer: Methylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses.

Context:
Diagnosis: Attention and concentration deficit; major depressive disorder
Treatment: Methylphenidate HCI 5MG
The proposed treatment is medically necessary.
The patient has a diagnosis of major depressive disorder, moderately severe and recurrent without psychotic features. He has a history of treatment refractory depression failing trials with six antidepressants: Lexapro, Zoloft, Wellbutrin, Cymbalta, Fetzima and Viibryd. He has experienced worsening episodes of depression over a ten year time interval associated with general medical illness. He is currently prescribed Luvox and Seroquel together with Xarelto, Losartan, atenolol-chlorthalidone and alprazolam.
The patient's current mental status examination reflects depressed mood with associated symptoms of anxiety, low interest and motivation, decreased concentration and fatigue, and, motor retardation. He is well groomed with clear speech and no evidence for mood cycling or mania, thought disorder, psychosis or severe cognitive impairment. Insight and judgment are fair. He has sleep disturbance with low energy and volition associated with social withdrawal. PHQ-9 is at 14 reflecting moderate symptoms of depression.
Methylphenidate 5 mg bid is prescribed for augmentation of his major depression with the treatment goal of improvement in functioning and symptoms of the major depressive disorder. Coverage for methylphenidate (Ritalin) to address the treatment-resistant depression is requested to address these target symptoms of low energy, motivation and mood, and to augment any other antidepressant medications. There are no other documented diagnoses of substance use disorder; or, co-morbid psychiatric diagnoses.
The use of stimulant medications including methylphenidate (Ritalin) is considered a clinically appropriate and effective augmentation strategy for the treatment of major depressive disorder in patients who are refractory/resistant to treatment with antidepressant medications. Moreover, the patient in this case has a likelihood of demonstrating a response to the current regimen that includes the starting dose of 5 mg bid with regard to symptoms of fatigue, low interest and motivation, and decreased concentration or focus, as well as the core symptoms of major depressive disorder.  The requested treatment has a reasonable expectation for improvement and/or maintenance treatment of major depressive disorder in a patient with treatment refractory depressive disorder and comorbid general medical illness associated with symptoms of low energy, fatigue, mood and motivation in keeping with the scientific literature concerning treatment refractory depression and medication augmentation strategies. the requested benefit of methylphenidate to address symptoms of moderately severe and recurrent major depressive disorder and/or to augment the antidepressant medication regimen is considered medically necessary in this case scenario, in keeping with prevailing standards of professional practice.

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


Answer: The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay.

Context: The patient was admitted from the emergency department for anemia and worsening renal failure with a plan to initiate dialysis. At issue is the medical necessity of the inpatient stay. The health plan's determination is upheld. The patient did not have evidence of an acute process contributing to the progression of the renal disease that required inpatient treatment.

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


Answer:
Diagnosis: Preterm rupture of membranes, vaginal bleeding
Treatment: Inpatient admission

Context:
Diagnosis: Preterm rupture of membranes, vaginal bleeding
Treatment: Inpatient admission
The inpatient admission was medically necessary.
Regardless of the duration of labor or hospital stay, inpatient level of labor and delivery care with associated nursing and other support is required for patient safety, pain relief, and psychological support that is not available from outpatient surgery resources for patients laboring and delivering at any gestational age.  In all cases, but especially in the circumstance of a perinatal demise and associated need for grief support and compassionate caregiving, specialized nursing support is needed for both physical and psychological wellbeing that would not be possible in an outpatient surgical unit.  Patients in this situation often are at risk for numerous hemorrhagic, infectious, and obstetrical complications that require specialized nursing and access to specialized hospital resources.  Therefore, this care should be provided in a standard labor and delivery environment and is medically necessary.

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


Answer: This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence.

Context: This is a patient with a medical history significant for depression, hyperlipidemia, fatigue, gait mobility, hypertension, osteoarthritis, obesity, unspecified pain and stress incontinence.  The health plan's determination of medical necessity is upheld.  The amount of hours provided are adequate to meet this patient's medical needs for the required services. An increase in service hours is not medically necessary for a decrease in endurance.

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