Answer: This male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.

Answer: Diagnosis: Bilateral below the elbow amputations.

Answer: Treatment: Prosthetic Arm Additions (extra socket for left artificial arm).

Answer: The insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm).

Context:
Diagnosis: Bilateral below the elbow amputations.

Treatment: Prosthetic Arm Additions (extra socket for left artificial arm).

The insurer denied coverage for Prosthetic Arm Additions (extra socket for left artificial arm).

The denial is upheld.

This male patient has bilateral below elbow amputations of the arms. A request for bilateral myoelectric prostheses has since been approved. However, the request for prosthetic arm additions (extra socket for artificial arms), that was separately coded as L7499, has been denied.

The insurer appropriately approved base code L6883 -Replacement socket, below elbow/wrist disarticulation, molded to patient mode, for use with or without external power.  However, the requested L7499 code- Skeletal contoured and dynamic below elbow socket- is an inappropriate unbundling code that should be incorporated into the base code of the replacement sockets (L6833).  Such unbundling of codes from the base code are inappropriate and have been previously adjudicated in case law.

The health plan acted reasonably, with sound medical judgement and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based.

The medical necessity is not substantiated. The carrier's denial of coverage for prosthetic arm additions (extra socket for artificial arms), should be upheld.

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


Answer: Diagnosis: Orthopedic/Musculoskeletal.

Answer: Treatment: Physical Therapy.

Answer: The insurer denied Physical Therapy Services for medical necessity.

Answer: This is a male patient that initially began receiving physical therapy service from a nonparticipating provider for impairments and functional deficits related to a knee surgery (anterior cruciate ligament (ACL) reconstruction). The patient had previously been participating in physical therapy for functional deficits related to the knee surgery. Documentation submitted indicated the patient had reached maximum therapeutic benefit with the care plan. It was noted the patient had completed 36 visits over several months.

Answer: The progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus."

Answer: There is a letter of medical necessity from the provider stating that the patient underwent left knee surgery. The patient was placed in a long brace locked an extension for 4 weeks after surgery and required the use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength, and ability to perform activities of daily living (ADL)s without limitation or pain. It was noted the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. It was felt the patient needed to undergo formal physical therapy for months to fully resolve these underlying issues and that it was the provider's standard protocol for all ACL reconstruction patients without any other type of setbacks after surgery to undergo a minimum of 6 months of formal physical therapy in order to make a full recovery.

Answer:
the patient underwent left knee surgery for right knee anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had 36 therapy sessions and appeared to progress well.
A progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus." The patient was actively performing exercises on the treadmill at 10 mph(miles per hour) and doing multiple exercises such as single leg hops, and squats holding for 10 seconds. The patient had been instructed in an independent home exercise program

Context:
Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Physical Therapy.

The insurer denied Physical Therapy Services for medical necessity.
The denial was upheld.

This is a male patient that initially began receiving physical therapy service from a nonparticipating provider for impairments and functional deficits related to a knee surgery (anterior cruciate ligament (ACL) reconstruction). The patient had previously been participating in physical therapy for functional deficits related to the knee surgery. Documentation submitted indicated the patient had reached maximum therapeutic benefit with the care plan. It was noted the patient had completed 36 visits over several months.
The progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus."
There is a letter of medical necessity from the provider stating that the patient underwent left knee surgery. The patient was placed in a long brace locked an extension for 4 weeks after surgery and required the use of crutches. He was enrolled in formal physical therapy to gradually restore his range of motion, strength, and ability to perform activities of daily living (ADL)s without limitation or pain. It was noted the patient was seen several times postoperatively and presented with disuse atrophy of the quadriceps muscles with his nerve supply intact. He had limited range of motion due to pain and swelling and was not strong enough to return to activity. It was felt the patient needed to undergo formal physical therapy for months to fully resolve these underlying issues and that it was the provider's standard protocol for all ACL reconstruction patients without any other type of setbacks after surgery to undergo a minimum of 6 months of formal physical therapy in order to make a full recovery.

The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Physical Therapy Services was not medically necessary for this patient.
Records provided indicate the patient underwent left knee surgery for right knee anterior cruciate ligament reconstruction. The patient was being treated for the same medical condition, postoperative knee rehabilitation following surgery and had been participating in physical therapy. The patient had 36 therapy sessions and appeared to progress well.
A progress note demonstrated very good clinical status with range of motion 0-125 and strength was "good to good plus." The patient was actively performing exercises on the treadmill at 10 mph(miles per hour) and doing multiple exercises such as single leg hops, and squats holding for 10 seconds. The patient had been instructed in an independent home exercise program and there was no indication that this patient would continue to require supervised therapy sessions rather than transitioning to a self-directed independent home exercise program as is the standard of care following the standard 24 visits of postoperative rehabilitation for this condition. There is no documentation to suggest that therapy performed in the skilled setting was required or that equivalent results could not be achieved while performing these exercises independently at home, which is the generally accepted standard of care.

Therefore, the Physical Therapy Services are not medically necessary.

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


Answer: Diagnosis: Dental Problems

Answer: Treatment: Dental/Orthodontic procedure

Answer: Diagnosis: Dental Problems-teeth spacing problem

Answer: Treatment: Dental/Orthodontic procedure-Braces and monthly visits

Answer: The health plan denied the treatment of Braces and monthly visits as not medically necessary.

Answer: The patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation.

Context:
Diagnosis: Dental Problems
Treatment: Dental/Orthodontic procedure

Diagnosis: Dental Problems-teeth spacing problem
Treatment: Dental/Orthodontic procedure-Braces and monthly visits
The health plan denied the treatment of Braces and monthly visits as not medically necessary.
The reviewer has overturned in whole the health plan
determination.

The patient has maxillary and mandibular crowding. The orthodontist mentioned in the diagnosis that #27 is impacted. Tooth #11 is blocked out to the labial. The patient is treatment planned for 36 months of comprehensive orthodontics with extraction of first premolars to create room with possible canine exposure and ligation.

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered.1 Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology.2 The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth.2 If left untreated the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason the treatment of braces and follow up visits is deemed medically necessary.

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


Answer: Diagnosis: Intractable back pain.

Answer: Treatment: Hospital admission.

Answer: The insurer denied coverage for the hospital admission.

Answer: This is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.

Answer: The patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain.

Context:
Diagnosis: Intractable back pain.

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is overturned.

This is a male patient with no significant past medical history who presented to the Emergency Department (ED) with intractable back pain. The patient also endorsed difficult ambulation and neck stiffness. In the ED, the patient received multiple pain medications including morphine without significant relief. The patient was unable to ambulate or sit up in the ED. Magnetic Resonance Imaging (MRI) of the lumbar spine was performed and the impression was: No acute fracture; no compression of the conus or cauda equine; annular bulge at L5-S1; transitional lumbosacral vertebra with lumbarization of S1; pseudoarthrosis of the transverse processes of the transitional vertebra with a sacral ala with bone marrow edema. It was noted that in the proper clinical setting, these findings could represent the initial presentation of Bertolotti syndrome. The patient was admitted to inpatient care for severe diffuse lower back pain bilaterally due to muscle spasm that resulted in the patient's inability to ambulate. Pain management was consulted and performed lumbar trigger point injection in the right lumbar paraspinal region, erector spinae and quadratus lumborum. The patient's pain improved but he experienced mild soreness in the lower back due to the injection. The patient was eventually able to ambulate on his own and was discharged with recommendations for outpatient Physical Therapy.

The patient was unable to sit up or ambulate. He was unable to perform his activities of daily living (ADLs) and received opiate medications for pain. These two factors are explicitly mentioned in the Milliman Care Guidelines (MCG) 24th Edition: Back Pain as criteria for admission.

Further, Joint Commission standards (2) require:
"The hospital reassesses and responds to the patient's pain though the following: ...
Progress toward pain management goals including functional ability (for example, ability to take a deep breath, turn in bed, walk with improved pain control."

The admission was required by the standard of care and was medically reasonable and necessary.

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

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.

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


Answer: The patient is a female with a past medical history notable for eczema and recent rhino/enterovirus upper respiratory tract infection with dehydration that presented to the Emergency Department for assessment and management of 1 day of watery, non-bloody stools and non-bloody, non-bilious vomiting.  Her mother notes irritability, fatigue and poor intake of solids but was drinking.  There was no associated fever, rashes, distention, low urine output or weight loss.  Of note the patient had been discharged after a 2-day admission the day prior to this presentation.

Answer: Diagnosis: Acute Viral Gastroenteritis

Answer: Treatment: Inpatient Admission

Answer: The insurer denied coverage for inpatient admission

Answer: This child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and minimal dehydration that responded to modest intravenous fluid repletion while in the Emergency Department.  The decision to admit her came after she demonstrated a successful oral challenge after a single normal saline bolus and one dose of Zofran, but refused to take additional volume.

Answer: her vomiting never recurred during the admission and no additional anti-emetics were required.

Answer: Her hypoglycemia resolved with supplementation.

Answer: she was able to tolerate fluids in the Emergency Department and a regular diet after admission.

Context:
Diagnosis: Acute Viral Gastroenteritis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female with a past medical history notable for eczema and recent rhino/enterovirus upper respiratory tract infection with dehydration that presented to the Emergency Department for assessment and management of 1 day of watery, non-bloody stools and non-bloody, non-bilious vomiting.  Her mother notes irritability, fatigue and poor intake of solids but was drinking.  There was no associated fever, rashes, distention, low urine output or weight loss.  Of note the patient had been discharged after a 2-day admission the day prior to this presentation.

This child appears to have had viral gastroenteritis with loose stools, self-limited vomiting and minimal dehydration that responded to modest intravenous fluid repletion while in the Emergency Department.  The decision to admit her came after she demonstrated a successful oral challenge after a single normal saline bolus and one dose of Zofran, but refused to take additional volume.  In accordance with a review of the approach to acute viral gastroenteritis in children in resource-rich countries from UpToDate the reasons to admit such an individual would include signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge (after treatment with anti-emetics and fluids), poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction.   She did not meet any of these criteria to merit the inpatient setting. Her vomiting and loose stool at home prior to anti-emetics that never recurred clearly does not equate to intractable vomiting as stated in the appeal.  In fact, her vomiting never recurred during the admission and no additional anti-emetics were required.

In regards to her volume status a second review of dehydration in children discusses the elements to assess the degree of dehydration. Uptodate.

The documentation of this child's appearance and vitals would indicate minimal dehydration that resolved by the time of the decision to admit to the hospital.  A venous lactate of 2.2 is insufficient to estimate her volume status.  Her hypoglycemia resolved with supplementation. After bolus fluid resuscitation in the Emergency Department, anti-emetics and observation the child could have avoided an unnecessary acute care admission.  Clearly the Zofran was sufficient as she was able to tolerate fluids in the Emergency Department and a regular diet after admission.  After a brief period of observation this patient could have been safely discharged with outpatient follow-up.  She actually received no acute care after admission to merit reimbursement at that level except for continued intravenous fluids despite tolerating feeds without issue once permitted. In regards to the acute inpatient admission the determination by the carrier that the admission was not medically necessary was correctly applied, objective, clinical valid, compatible with established principles of health care and flexible enough to permit justified variation. This decision was rendered based on review of the hospital record and the reviews from Uptodate summarizing the approach to nausea/vomiting and dehydration in children in cited above.

Uphold denial of coverage for acute inpatient admission. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

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


Answer: This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year.

Answer: Diagnosis: idiopathic short stature

Answer: Treatment: Nutropin

Answer: The insurer denied Nutropin.

Context:
Endocrine
Growth Hormone

Diagnosis: idiopathic short stature
Treatment: Nutropin
The insurer denied Nutropin. The health plan's determination is overturned.

This is a female diagnosed with idiopathic short stature (ISS). This request is for Nutropin. Her growth hormone (GH) stimulation test with arginine and clonidine peaked at 13.10. Her genitourinary (GU) was at tanner 1. Her Insulin-like Growth Factor 1 (IGF1) was 184. Her height velocity is reported to be 3.4 centimeter (cm) /year.

Nutropin is medically necessary for this patient. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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


Answer: Diagnosis: Alzheimer's disease and a closed fracture of multiple ribs of the left side with routine healing.

Answer: Treatment: Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.

Answer: The insurer denied coverage for Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.

Answer: This is a female patient with a past medical history of Alzheimer's disease, hyperlipidemia, chronic obstructive pulmonary disease, urinary incontinence, esophageal reflux disease, obesity, iron deficiency anemia, anxiety, diabetes mellitus, hypoxia, a closed fracture of multiple ribs of the left side with routine healing, nausea, interstitial lung disease, Rheumatoid factor positive, polycythemia and pain. She has significant functional impairment associated with various medical conditions. The patient lives with her daughter and grandchildren. She receives consumer directed personal assistance program services (CDPAP) services. The patient was approved for CDPAP 20 hours per week (4 hours per day, 5 days per week). The patient's daughter requested CDPAP 56 hours per week (8 hours per day, 7 days per week) which was denied, but the insurer increased CDPAP services to 5.5 hours per day, 7 days per week; total 38.5 hours per week. The patient's daughter requested an external appeal as designee for the patient.

Answer: Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs); except phone use, stairs, transportation (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision).

Context:
Diagnosis: Alzheimer's disease and a closed fracture of multiple ribs of the left side with routine healing.
Treatment: Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week.
The denial is overturned.

This is a female patient with a past medical history of Alzheimer's disease, hyperlipidemia, chronic obstructive pulmonary disease, urinary incontinence, esophageal reflux disease, obesity, iron deficiency anemia, anxiety, diabetes mellitus, hypoxia, a closed fracture of multiple ribs of the left side with routine healing, nausea, interstitial lung disease, Rheumatoid factor positive, polycythemia and pain. She has significant functional impairment associated with various medical conditions. The patient lives with her daughter and grandchildren. She receives consumer directed personal assistance program services (CDPAP) services. The patient was approved for CDPAP 20 hours per week (4 hours per day, 5 days per week). The patient's daughter requested CDPAP 56 hours per week (8 hours per day, 7 days per week) which was denied, but the insurer increased CDPAP services to 5.5 hours per day, 7 days per week; total 38.5 hours per week. The patient's daughter requested an external appeal as designee for the patient.

Uniform Assessment System (UAS) documentation was provided for review. The functional status report indicates the patient is totally dependent or needs maximal assistance for most instrumental activities of daily living (IADLs); except phone use, stairs, transportation (limited assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing, lower body dressing, toilet use. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision).

Considering the patient's medical history, and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present to provide assistance with ADLs and IADLs when needed, including ADLs that occur at unplanned times throughout the day and night, including: toileting, incontinence care, transfers and ambulation. Caregiver assistance is needed to help prevent adverse health and safety events.

Assistance from informal caregivers is voluntary as per New York State (NYS) regulations for personal care services. When informal caregivers are unable to provide care on a consistent basis, then personal care services (in this case CDPAP) are indicated to provide the patient with assistance for daily activities when necessary throughout the day and night. If the patient's care needs become more frequent and/or the family's ability to provide informal care decreases, re-assessment will be needed to determine if CDPAP 8 hours per day can adequately meet the patient's personal care needs.

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

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Program services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical necessity is substantiated.

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


Answer: Diagnosis: Status Asthmaticus

Answer: Treatment: Inpatient Hospital Admission

Answer: The insurer denied coverage for inpatient hospital admission

Answer: The patient is an obese male with a history of asthma and one previous admission for asthma. He had been sick for three days with upper respiratory infection (URI) symptoms. He then developed difficulty breathing and coughing and received 8 albuterol nebulizer treatments at home. When his respiratory symptoms did not improve with treatment for asthma at home his mother brought him to the Emergency Room (ER) for further treatment. His sister was also sick and had been admitted to the hospital with asthma.  In the ER, he was noted to have an increased work of breathing with tachycardia, shortness of breath, retractions and coarse breath sounds. He was treated with duoneb and albuterol every 2 hours. He required oxygen supplementation with 4 liters of oxygen at 28 percent. He was then switched to continuous albuterol when his breathing rate deteriorated and he became more short of breath. His mother agreed to treatment with intravenous (IV) dexamethasone and magnesium sulfate. His venous blood gas was 7.42 with a partial pressure of carbon dioxide (PCO2) of 42 indicating significant respiratory distress. He was transferred to the Pediatric Intensive Care Unit (PICU) for intensive asthma therapy.

Answer: The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

Answer: He did require oxygen supplementation for ongoing hypoxemia. He had a history of previous asthma admission and had failed outpatient therapy for asthma exacerbation.

Context:
Diagnosis: Status Asthmaticus

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

The patient is an obese male with a history of asthma and one previous admission for asthma. He had been sick for three days with upper respiratory infection (URI) symptoms. He then developed difficulty breathing and coughing and received 8 albuterol nebulizer treatments at home. When his respiratory symptoms did not improve with treatment for asthma at home his mother brought him to the Emergency Room (ER) for further treatment. His sister was also sick and had been admitted to the hospital with asthma.  In the ER, he was noted to have an increased work of breathing with tachycardia, shortness of breath, retractions and coarse breath sounds. He was treated with duoneb and albuterol every 2 hours. He required oxygen supplementation with 4 liters of oxygen at 28 percent. He was then switched to continuous albuterol when his breathing rate deteriorated and he became more short of breath. His mother agreed to treatment with intravenous (IV) dexamethasone and magnesium sulfate. His venous blood gas was 7.42 with a partial pressure of carbon dioxide (PCO2) of 42 indicating significant respiratory distress. He was transferred to the Pediatric Intensive Care Unit (PICU) for intensive asthma therapy.

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

According to Sawicki and Haver, "GENERAL APPROACH - Most children who require admission for asthma are initially treated in the emergency department (ED), although some are admitted directly from clinicians' offices. Thus, inpatient treatment is typically a continuation of therapies and monitoring that were started in the ED. Patients usually have received several albuterol treatments, often combined with ipratropium (children with an asthma exacerbation experience a lower risk of admission to the hospital if they are treated with the combination of inhaled short-acting beta agonists [SABAs] plus anticholinergic versus SABA alone, systemic glucocorticoids, and supplemental oxygen, when necessary, before arrival to the inpatient unit."

According to Scarfone, "DISPOSITION - The decision regarding disposition (eg, discharge to home, continued observation, or hospitalization) is based upon both clinical and social factors. Discharge to home - Children who have marked improvement in clinical parameters within the first one to two hours of therapy may be discharged home. Marked improvement is manifested by diminished or absent wheezing and retracting and increased aeration that is sustained at least 60 minutes after the most recent albuterol dose. Hospitalization - Patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation."

The patient was treated appropriately in the ER for status asthmaticus. He did require oxygen supplementation for ongoing hypoxemia. He had a history of previous asthma admission and had failed outpatient therapy for asthma exacerbation. His hypoxemia and respiratory distress with elevated venous pCO2 of 42 demonstrated that he was not stable enough to be discharged. The decision to admit him to the hospital for ongoing treatment was appropriate and consistent with the standard of care for status asthmaticus.

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

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical necessity is substantiated.

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


Answer: The patient is a male with psoriasis. He has tried and failed betamethasone for one year. He has been on Ilumya with great improvement; his body surface area affected is currently 0%. The subject under review is the medical necessity of the Ilumya 100 milligrams per milliliter (MG/ML).

Answer: Diagnosis: Skin Disorders.

Answer: Treatment: Pharmacy/Prescription Drugs.

Answer: The insurer denied Ilumya 100 milligrams per milliliter (MG/ML).

Context:
Diagnosis: Skin Disorders.
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Ilumya 100 milligrams per milliliter (MG/ML).
The denial is upheld.

The patient is a male with psoriasis. He has tried and failed betamethasone for one year. He has been on Ilumya with great improvement; his body surface area affected is currently 0%. The subject under review is the medical necessity of the Ilumya 100 milligrams per milliliter (MG/ML).

The health plan's determination is upheld in whole.

The requested health treatment of Ilumya 100MG/ML is not medically necessary for this patient. There is no documentation that the patient has tried and failed, has an intolerance to, or contraindication to the preferred therapies, making Ilumya medically necessary.
There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Ilumya for this patient's condition as an accepted standard of practice in the U.S.
There are no comparative, controlled studies showing that Ilumya has a superior efficacy to the health plan's preferred alternatives, such as phototherapy and methotrexate.
Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (2). Mehta et al. writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrow band ultraviolet B (NB-UVB) ...effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (3).
Additionally, West et al. 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (4).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the documentation provided, the request for Ilumya is not necessary. The patient has not tried and/or failed a preferred agent. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Ilumya medically more appropriate than the other options. Therefore, the administration of Ilumya is not strongly supported for this patient and is not medically necessary.

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


Answer: This is a male patient who was admitted to the hospital for alcohol detoxification, as he had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis.  He reportedly was requesting detoxification from alcohol and cocaine.  He reportedly was drinking 1/2 bottle of whiskey and 5-6 beers daily as well as cocaine daily and cannabis daily.  He reportedly occasionally used ecstasy.  His chest x-ray reportedly revealed pleural effusion, left basilar lung infiltrate, and atelectasis.  He reportedly was put on a Librium taper and also had intravenous (IV) Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.

Answer: He reportedly had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis, pleural effusion, left basilar lung infiltrate, and atelectasis and had a history of pulmonary embolism and deep vein thrombosis.  He was considered a medical risk and due to his multiple medical issues and he had reports of active alcohol moderate withdrawal symptoms including tremors, nausea, headache, and sensitivity to light.  He was put on a Librium taper and also had IV Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.

Answer: Diagnosis: Alcohol withdrawal.

Answer: Treatment: Inpatient hospital admission.

Answer: The insurer denied coverage for the inpatient hospital admission.

Context:
Diagnosis: Alcohol withdrawal.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned.

This is a male patient who was admitted to the hospital for alcohol detoxification, as he had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis.  He reportedly was requesting detoxification from alcohol and cocaine.  He reportedly was drinking 1/2 bottle of whiskey and 5-6 beers daily as well as cocaine daily and cannabis daily.  He reportedly occasionally used ecstasy.  His chest x-ray reportedly revealed pleural effusion, left basilar lung infiltrate, and atelectasis.  He reportedly was put on a Librium taper and also had intravenous (IV) Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.  This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to large amounts of daily alcohol use, and also was using cocaine daily, and he reportedly had  co-morbid medical issues complicating the management of withdrawal.  He reportedly had alcohol withdrawal symptoms including tremors, nausea, headache, and sensitivity to light, and also had alcohol gastritis, pleural effusion, left basilar lung infiltrate, and atelectasis and had a history of pulmonary embolism and deep vein thrombosis.  He was considered a medical risk and due to his multiple medical issues and he had reports of active alcohol moderate withdrawal symptoms including tremors, nausea, headache, and sensitivity to light.  He was put on a Librium taper and also had IV Pepcid and ondansetron, thiamine, folic acid, multivitamin, and IV fluids.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting  as he continued to use large amounts of  alcohol and cocaine daily despite medical issues and he required and needed detoxification medication to modify withdrawal including a Librium taper and needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then, including severe and life threatening withdrawal symptoms.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment and was at risk medically as he had active medical issues putting him at risk medically as well and required 24-hour hospital treatment.

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

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

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


Answer: Diagnosis: Overbite.

Answer: Treatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.

Answer: The insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.

Answer: The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.

Answer: Patient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.

Answer: The health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.

Answer: The patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth.

Context:
Diagnosis: Overbite.
Treatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.

Patient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.

The health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.

Yes, the orthodontic therapy (Braces) and periodic orthodontic treatment visits are medically necessary.
The patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth. This is evident on the intra-oral photos of the upper anterior gum area.

A severe overbite like this can result in gum recession, and eventually gum disease and possible tooth loss. Difficulty with speech and chewing are also a possible consequence of this condition.

Therefore, given the above, the braces and visits are medically necessary.

As evidenced in the x-rays and the photos, the severity of the overbite and the other conditions of the patient's dentition warrants orthodontic treatment.

The long-term consequences of not treating these conditions would lead to more complications of the patient's dentition, and would thus affect the patient's overall health.

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


Answer: Diagnosis: Low Platelets

Answer: Treatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing

Answer: The insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.

Answer: The patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.

Answer: Bone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.

Answer: The patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.

Answer: No treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.

Answer: The patient had a bone marrow biopsy done that revealed

Answer: T-cell immunophenotypic changes

Context:
Diagnosis: Low Platelets
Treatment: T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing
The insurer denied the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing.
The denial is upheld.

The patient is a female.  She has a history of thrombocytopenia.  This had been present for one year.  She was noted to have positive antiphospholipid antibody titers.  It was noted that she had splenic lesions that felt consistent with splenic lymphangiomatosis.

Bone marrow biopsy was done and revealed mild fibrosis and normal hematopoiesis.  Flow cytometry revealed mild T-cell immunophenotypic changes.

The patient's CBC (complete blood count) was notable for normal white cell count, normal hemoglobin, and platelet count of 118.  CBC (complete blood count) testing prior was notable for mild leukopenia.

No treatment was recommended, but the patient's physician ordered a blood T-cell clonality study.

No, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.

There is no evidence supporting the medical necessity of this test.  The patient had a bone marrow biopsy done that revealed "mild" T-cell immunophenotypic changes, but did not reveal clear evidence suggesting presence of T-cell lymphoma.  There is no abnormal white cell population noted in peripheral blood.  There is no neutropenia.  Cytopenias are a presenting finding in patients with T-cell large granular lymphocytic leukemia, but there is also no indication that this patient has been found to have an abnormal population of LGL (large granular lymphocyte) cells.  Also, LGL (large granular lymphocyte) leukemia is commonly associated with neutropenia, and CBC (comprehensive blood count) testing in this case is not notable for neutropenia.

Therefore, given the above, the T-Cell Clonality Panel and TRB (T-cell antigen receptor, beta) Gene Testing was not medically necessary.

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


Answer: The patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.

Answer: The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past.

Answer: Diagnosis: Gastroesophageal reflux disease without esophagitis.

Answer: Treatment: Sucralfate suspension.

Answer: The insurer denied Sucralfate suspension.

Context:
Diagnosis: Gastroesophageal reflux disease without esophagitis.
Treatment: Sucralfate suspension.
The insurer denied Sucralfate suspension.
The determination is overturned.

The patient is a male with gastroesophageal reflux disease (GERD) complicated by Barrett's esophagus, hiatal hernia status post Nissen's fundoplication, peptic ulcer disease with duodenal ulcer, and gastroparesis. He has had chronic dyspepsia and abdominal discomfort. He could not tolerate sucralfate tablets. Coverage is being requested for sucralfate suspension.

A formulary exception is indicated in this case. The submitted documentation reports that the patient attempted and failed sucralfate tablets in the past. Sucralfate (Carafate) is effective for the treatment of gastroesophageal reflux disease (GERD) symptoms. It is also effective for the treatment of peptic ulcer disease and dyspepsia associated with duodenogastric reflux. Sucralfate is available in tablet and liquid suspension forms, with similar reported efficacy and adverse effects, although the suspension has different physical characteristics which can result in easier traversion of the esophagus and different physical distribution in the stomach. As the patient has failed the tablet form, use of the suspension can be effective.

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


Answer: Diagnosis: Low Red Blood Cell Count (anemia).

Answer: Treatment: Inpatient admission.

Answer: The insurer denied the inpatient admission.

Answer: The patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.

Answer: The patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).

Answer: Day two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.

Answer: On day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.

Answer: On day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged.

Context:
Diagnosis: Low Red Blood Cell Count (anemia).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with history of NSAID (nonsteroidal anti-inflammatory drug) use. He presented to the ER (emergency room) with anemia. As an outpatient, his Hgb (hemoglobin) was 7.3. He had recent black stool. He complained of some epigastric pain. He denied any NV (nausea and vomiting), hemetemesis, bright red blood per rectum or current melena.

The patient was hemodynamically stable. His Hgb (hemoglobin) was 7.4. He was transfused 2 units of PRBCs (packed red blood cells).

Day two, the patient's Hgb (hemoglobin) was 9.3. He was placed on PPIs (proton pump inhibitors) and seen by GI (gastroenterology). EGD (esophagogastroduodenoscopy) was scheduled.

On day two, three and four, there was no hemetemesis, melena or bright red blood per rectum.

On day five, Hgb (hemoglobin) was 10.7. EGD (esophagogastroduodenoscopy) revealed a duodenal ulcer, and the patient was discharged.

No, the Inpatient admission was not medically necessary.
The patient was hemodynamically stable, without evidence of active bleeding. He had no sepsis, coagulopathy, history of cirrhosis or any other significant co-morbidities. Therefore, treatment at a lower level care status was medically appropriate on day one. On day two, when his Hgb (hemoglobin) was up to 9.3, the patient was medically stable for discharge to outpatient care, or for EGD (esophagogastroduodenoscopy) at a lower level of care, and then discharged. Acute inpatient hospital stay was not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
As above, as a lower level of care status was medically appropriate, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying the acute inpatient hospital stay.

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


Answer: The patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.

Answer: Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins

Answer: Treatment: Sclerotherapy

Answer: The insurer denied coverage for sclerotherapy.

Context:
Diagnosis: Bilateral Lower Extremity Symptomatic Varicose Veins

Treatment: Sclerotherapy

The insurer denied coverage for sclerotherapy.

The denial is upheld.

The patient has been recommended to undergo bilateral sclerotherapy due to failure of conservative treatment.  The documentation indicated she has had a trial of conservative care.  This included over-the-counter medication in addition to elevation as well as compression without relief.  She continues to suffer from ongoing pain and has had treatment with the bilateral phlebectomy.  Later, she was seen with complaints of bilateral lower extremity symptomatic varicose veins.  The physical examination revealed there was mild edema bilaterally to the lower extremities.  Motor and sensation were intact.  Her bilateral leg incisions were well-healing and there were dense clusters of spider veins bilaterally.  The documentation indicated she had bilateral lower extremity symptomatic varicose veins despite compression in the absence of reflux and therefore it was recommended she undergo a bilateral sclerotherapy procedure.  A duplex revealed no evidence of venous reflux to the right lower extremity with evidence of focal venous reflux in the small saphenous vein to the left lower extremity.

The proposed sclerotherapy treatments bilaterally are not medically necessary.  There is no evidence of reflux in the right lower extremity.  There is reflux in the left lower extremity, but the degree and severity of reflux in the left sapheno-popliteal junction is not quantified on the venous reflux report.

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

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

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


Answer: The patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).

Answer: Diagnosis: Thyroid nodule.

Answer: Treatment: Thyroid Radiofrequency Ablation.

Answer: The insurer denied the Thyroid Radiofrequency Ablation.

Answer: The patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.

Answer: As reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative.

Context:
Diagnosis: Thyroid nodule.
Treatment: Thyroid Radiofrequency Ablation.
The insurer denied the Thyroid Radiofrequency Ablation.
The denial is overturned.

The patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.

As reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative.

Yes, the Thyroid Radiofrequency Ablation is medically necessary.
The American Association of clinical endocrinologists guidelines [1] recommend radiofrequency ablation of solid thyroid nodules if they are large or symptomatic. This is grade A evidence. The solid component of the nodules should be sampled prior to ablation to show the absence of malignancy. This is supported by multiple studies including a meta-analysis [2].

The patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).

The request is not for the convenience of the patient or provider. It is not part of a study. It is clinically appropriate. The request for radiofrequency ablation of the nodule is consistent with generally accepted standards of medical practice and is therefore medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, as the request is medically necessary as described above.

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


Answer: The patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

Answer: In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks

Answer: Diagnosis: Crohn's Disease

Answer: Treatment: Stelara (90 mg every 4 weeks)

Answer: The insurer denied Stelara (90 mg every 4 weeks).

Context:
Diagnosis: Crohn's Disease
Treatment: Stelara (90 mg every 4 weeks)
The insurer denied Stelara (90 mg every 4 weeks).
The health plan's determination is overturned.

The patient has Crohn's disease status post total colectomy with ileoanal pouch anastomosis. The patient has failed prednisone, antibiotics, cyclosporine, and Remicade. The patient was started on Stelara. Due to only partial improvement, the dose was escalated to every 4 weeks with good control of disease. The coverage is requested to continue Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease.

The request for Stelara to 90 mg every 4 weeks is supported as medically necessary by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease and pouchitis [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient has severe disease based on need for surgery. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% (percent) of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4]. In this case, the patient has failed Stelara every 8 weeks, and has had disease control on Stelara 90 mg every 4 weeks; discontinuation of dosing every 4 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported to be more beneficial than any standard treatment or treatments in this case and is medically necessary by current medical literature.

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


Answer: In this child's case, she was an infant at the time of her scald burn. She sustained second degree burns of her right-hand including fingers and joints. She was initially managed in the ED, but following initial wound care, was placed in observation status for the first wound care/dressing change. Upon evaluation, the burn was considerably deeper in some areas than previously thought. She was converted at that time to full inpatient status, and local wound care was continued.

Answer: Diagnosis: Trauma/Injuries.

Answer: Treatment: Inpatient Hospital.

Answer: The insurer denied inpatient stay.

Answer: The patient is a female who was taken to the emergency department (ED) following scald burn to the right hand. Hot tea spilled on her right hand from a tea kettle. She was treated with Tylenol and running under cool water at home with some symptomatic relief.

Answer: Vital signs included temperature 98.6, heart rate 132, respiratory rate 28, and blood pressure 104/69. Examination was significant for no acute distress, mild tachycardia, moist mucous membranes, blistering on the first three digits crossing the metacarpal joint line with surrounding erythema, and blistering of the palm and radial aspect of the fourth digit. She was diagnosed with second-degree partial thickness burn of 0.5% body surface area involving the right hand. She was treated with ibuprofen and fentanyl. Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 22.06 thousand [K]). The burn service was consulted with recommendation for admission for observation. Admission orders included physical therapy (PT)/occupational therapy (OT) evaluation, non-excisional debridement and cleansing with chlorhexidine, daily wound care with collagenase and gentamicin, attending wound check after 24 hours of collagenase and gentamicin, pain control as needed, and diet as tolerated.

Answer: The following day, her pain was well-controlled, she was eating and drinking, and she was afebrile. However, during the wound check, the burns appeared to be significantly deeper than initially thought. At that point, her status was converted from observation level of care to acute inpatient level of care for continuing local wound care and ongoing re-evaluation of her wound status. There was some consideration for discharge, but upon wound evaluation during dressing change, the burns on the dorsum of the fingers were still quite deep. The palmar aspect of the hand was healing quite well. Local wound care was continued with collagenase and gentamicin using ibuprofen and morphine for pain management, and consideration was given for possible surgical intervention. During wound evaluation, there was still a small section on the dorsum of the index finger extending down into the first web space that was fairly deep, but the remainder of the wounds were healing well. Local wound care was recommended, and family teaching was initiated. She underwent dressing change, at which time the wounds were placed into Mepilex. She was discharged home for follow-up in Burn Clinic.

Context:
Diagnosis: Trauma/Injuries.
Treatment: Inpatient Hospital.
The insurer denied inpatient stay.
The denial is overturned.

The patient is a female who was taken to the emergency department (ED) following scald burn to the right hand. Hot tea spilled on her right hand from a tea kettle. She was treated with Tylenol and running under cool water at home with some symptomatic relief.
Vital signs included temperature 98.6, heart rate 132, respiratory rate 28, and blood pressure 104/69. Examination was significant for no acute distress, mild tachycardia, moist mucous membranes, blistering on the first three digits crossing the metacarpal joint line with surrounding erythema, and blistering of the palm and radial aspect of the fourth digit. She was diagnosed with second-degree partial thickness burn of 0.5% body surface area involving the right hand. She was treated with ibuprofen and fentanyl. Laboratory evaluation was significant for leukocytosis (white blood cell [WBC] count 22.06 thousand [K]). The burn service was consulted with recommendation for admission for observation. Admission orders included physical therapy (PT)/occupational therapy (OT) evaluation, non-excisional debridement and cleansing with chlorhexidine, daily wound care with collagenase and gentamicin, attending wound check after 24 hours of collagenase and gentamicin, pain control as needed, and diet as tolerated.
The following day, her pain was well-controlled, she was eating and drinking, and she was afebrile. However, during the wound check, the burns appeared to be significantly deeper than initially thought. At that point, her status was converted from observation level of care to acute inpatient level of care for continuing local wound care and ongoing re-evaluation of her wound status. There was some consideration for discharge, but upon wound evaluation during dressing change, the burns on the dorsum of the fingers were still quite deep. The palmar aspect of the hand was healing quite well. Local wound care was continued with collagenase and gentamicin using ibuprofen and morphine for pain management, and consideration was given for possible surgical intervention. During wound evaluation, there was still a small section on the dorsum of the index finger extending down into the first web space that was fairly deep, but the remainder of the wounds were healing well. Local wound care was recommended, and family teaching was initiated. She underwent dressing change, at which time the wounds were placed into Mepilex. She was discharged home for follow-up in Burn Clinic.

Acute inpatient stay was medically necessary and appropriate for this infant. She had initially been admitted observation status but because of the severity of the burn was appropriately converted to acute inpatient status. In this child's case, she was an infant at the time of her scald burn. She sustained second degree burns of her right-hand including fingers and joints. She was initially managed in the ED, but following initial wound care, was placed in observation status for the first wound care/dressing change. Upon evaluation, the burn was considerably deeper in some areas than previously thought. She was converted at that time to full inpatient status, and local wound care was continued. As the burn injury continued to progress, there was even consideration for surgical intervention. Based on the current standard of care and the evolving damage that became evident over time during wound care, acute inpatient status was medically necessary and appropriate. Her medical needs exceeded what could be proved as observation status.

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


Answer: The patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.

Answer: Diagnosis: Multiple Sclerosis.

Answer: Treatment: Tecfidera DR 240mg.

Answer: The insurer denied the Tecfidera DR 240mg.

Context:
Diagnosis: Multiple Sclerosis.
Treatment: Tecfidera DR 240mg.
The insurer denied the Tecfidera DR 240mg.
The denial is upheld.

The patient is a woman with relapsing remitting multiple sclerosis who is currently taking Tecfidera. She was previously on Copaxone and switched to Tecfidera due to breakthrough disease. She is currently stable on Tecfidera. The request for continued Tecfidera was previously denied as brand name Tecfidera is not in the plan formulary and it has not been documented that patient has tried and is intolerant of generic dimethyl fumarate.

No, the Tecfidera is not medically necessary.

The Tecfidera is not medically necessary, as no justification or rationale is provided as to why there is a medical exception for continuation of Tecfidera without trying generic dimethyl fumarate, which has been approved by the FDA (United States Food and Drug Administration). There is no available data comparing Tecfidera and generic dimethyl fumarate in regards to efficacy and safety.

Therefore, the Tecfidera is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Dimethyl fumarate in the generic form is the same ingredient as Tecfidera, and there is no evidence in the medical literature that supports the use of Tecfidera over generic dimethyl fumarate.

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


Answer: The patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics (braces) to correct his malocclusion.

Answer:
Diagnosis: Class I Occlusion
Treatment: Braces

Answer: The insurer denied braces.

Context:
Diagnosis: Class I Occlusion
Treatment: Braces

The insurer denied braces.
The health plan's determination is upheld.

The patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics (braces) to correct his malocclusion.

There is no medical reason to correct this patient's malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6 mm. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.

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


Answer: Diagnosis: Status Post 2 Kidney Transplants.

Answer: Treatment: Egg Retrieval with Fertilization of the Eggs.

Answer: The patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.

Answer: The patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.

Answer: The request for services have been denied as the patient does not meet criteria for the use of IVF treatment.

Context:
Diagnosis: Status Post 2 Kidney Transplants.
Treatment: Egg Retrieval with Fertilization of the Eggs.

The insurer denied Egg Retrieval with Fertilization of the Eggs.  The denial is upheld.

The patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.

The patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.

The request for services have been denied as the patient does not meet criteria for the use of IVF treatment.

The health plan's determination is upheld.

The requested egg retrieval with fertilization of the eggs is not medically necessary for this patient.

There have been no studies to determine the patient's fertility status. Given her age, she may not meet criteria for starting fertility treatment. There is no evaluation of her partner to determine if there are any infertility issues. The patient does not meet standard criteria for IVF treatment.

Based on the standard of care, it is reasonable to consider IVF for this patient due to her medical condition (chronic renal failure with renal transplant).  However, there was no evidence presented to show what her fertility potential is and/or any information on her reproductive history.  Without fully evaluating this patient to even see if she is a candidate for infertility treatment, one cannot approve aggressive treatment.  Standard of care requires that a patient and her partner have an initial work-up to look for all potential infertility issues.  None of this was done.  Therefore, this patient does not meet standard criteria for IVF.

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


Answer: The patient is a male was admitted to this inpatient hospital for cellulitis of both legs, hematoma, and deep vein thrombosis (DVT) in his arm, and alcohol detoxification. He had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) score of 9 and was very tremulous, agitated, nauseous, had anxiety, headache, and tactile hallucinations of bugs crawling on him. He was verbally abusive to staff. The patient was drinking 3 liters of alcohol per day. He reportedly was homeless. He had a diagnosis of schizophrenia, gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD). The patient was involved in an altercation prior to admission and fell and was hurt. He was given Ativan 2 mg (milligrams) and put on an Ativan CIWA protocol and taper which concluded. He reportedly was put on 2 intravenous (IV) antibiotics including Cefazolin and Clindamycin for cellulitis and fungal treatment, and also given Lovenox for his DVT. The patient was discharged when his IV antibiotics were completed, and he was given oral antibiotics including Keflex and Eliquis for his DVT.

Answer: Diagnosis: Alcohol Withdrawal.

Answer: Treatment: Inpatient Admission.

Answer: The insurer denied coverage for inpatient admission.

Answer: He also had significant medical problems including cellulitis and DVT requiring IV antibiotics and Lovenox. He reportedly was homeless with a diagnosis of schizophrenia

Answer: He was put on a CIWA protocol with an Ativan taper for alcohol detoxification

Answer: He also was homeless and lacked supports and coping skills and the ability to care for his acute medical needs.

Context:
Diagnosis: Alcohol Withdrawal.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient is a male was admitted to this inpatient hospital for cellulitis of both legs, hematoma, and deep vein thrombosis (DVT) in his arm, and alcohol detoxification. He had a Clinical Institute Withdrawal Assessment Alcohol (CIWA) score of 9 and was very tremulous, agitated, nauseous, had anxiety, headache, and tactile hallucinations of bugs crawling on him. He was verbally abusive to staff. The patient was drinking 3 liters of alcohol per day. He reportedly was homeless. He had a diagnosis of schizophrenia, gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD). The patient was involved in an altercation prior to admission and fell and was hurt. He was given Ativan 2 mg (milligrams) and put on an Ativan CIWA protocol and taper which concluded. He reportedly was put on 2 intravenous (IV) antibiotics including Cefazolin and Clindamycin for cellulitis and fungal treatment, and also given Lovenox for his DVT. The patient was discharged when his IV antibiotics were completed, and he was given oral antibiotics including Keflex and Eliquis for his DVT.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.

Also, the US (United States) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment, if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient had several comorbid medical conditions complicating the management of withdrawal and he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment.

He also had significant medical problems including cellulitis and DVT requiring IV antibiotics and Lovenox. He reportedly was homeless with a diagnosis of schizophrenia and was unable to care for his medical needs if not in this 24-hour hospital. He was put on a CIWA protocol with an Ativan taper for alcohol detoxification which was complete but still required hospitalization for further IV antibiotic treatment of his cellulitis. He was at risk of sepsis if this were not treated and he likely would have been noncompliant as he was homeless and drinking 3 liters of alcohol daily and had a diagnosis of schizophrenia.

He did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care and also unsafe for him to be treated medically outside of a hospital setting due to his acute medical issues requiring hospital treatment. He also was homeless and lacked supports and coping skills and the ability to care for his acute medical needs. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment.

The health care plan did not act reasonably, with sound medical judgment, or in the best interests of the patient.

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

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


Answer: This is the case of a patient with a past medical history of gastroesophageal (GERD) and hypertension (HTN) who presented to the emergency department (ED) with the complaint of abdominal pain. He was afebrile with stable vital signs. As per the ED provider note, he complained of left flank pain since midnight. He reported no history of similar pain in the past. He had nausea but no vomiting. He denied fevers. He had a recent esophagogastroduodenoscopy (EGD) which showed acute gastritis. On exam, he had a soft abdomen, non-distended, tender to palpation in the epigastrium.  He had a HIDA (hepatobiliary iminodiacetic acid) scan which was positive by report for acute cholecystitis. Surgery was called to see the patient. He also had a computed tomography (CT) of the abdomen. He was made aware of renal cyst and instructed for this to have follow up with urology. As per the history and physical he presented with nausea and abdominal pain. His labs showed a white blood count (WBC) of 9.10 liver function test (AST [aspartate aminotransferase] 27, ALT [Alanine transaminase]24), Alkaline Phosphatase 59 and bilirubin total of 1. He was made NPO [nothing by mouth] and plan for OR [operating room] tomorrow for laparoscopic (lap) cholecystectomy.

Answer: Diagnosis: Acute Cholecystitis

Answer: Treatment acute inpatient admission

Answer: The insurer denied coverage for acute inpatient admission

Answer: the patient underwent an MRCP (Magnetic resonance cholangiopancreatography)

Answer: He subsequently had the lap cholecystectomy.

Answer: His HIDA scan was positive for acute cholecystitis

Context:
Diagnosis: Acute Cholecystitis

Treatment acute inpatient admission

The insurer denied coverage for acute inpatient admission

The denial is upheld

This is the case of a patient with a past medical history of gastroesophageal (GERD) and hypertension (HTN) who presented to the emergency department (ED) with the complaint of abdominal pain. He was afebrile with stable vital signs. As per the ED provider note, he complained of left flank pain since midnight. He reported no history of similar pain in the past. He had nausea but no vomiting. He denied fevers. He had a recent esophagogastroduodenoscopy (EGD) which showed acute gastritis. On exam, he had a soft abdomen, non-distended, tender to palpation in the epigastrium.  He had a HIDA (hepatobiliary iminodiacetic acid) scan which was positive by report for acute cholecystitis. Surgery was called to see the patient. He also had a computed tomography (CT) of the abdomen. He was made aware of renal cyst and instructed for this to have follow up with urology. As per the history and physical he presented with nausea and abdominal pain. His labs showed a white blood count (WBC) of 9.10 liver function test (AST [aspartate aminotransferase] 27, ALT [Alanine transaminase]24), Alkaline Phosphatase 59 and bilirubin total of 1. He was made NPO [nothing by mouth] and plan for OR [operating room] tomorrow for laparoscopic (lap) cholecystectomy.

There was no indication in the chart for the delay in surgery as the HIDA scan was positive, and the patient underwent an MRCP (Magnetic resonance cholangiopancreatography) despite having normal liver function tests. He subsequently had the lap cholecystectomy. This could have been done sooner and in an observation, status as noted by the insurer with the patient discharged within 48 hours of presentation if not sooner.

According to the guidelines of Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care- 26th edition Gall bladder or bile duct inflammation or stone, patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The  clinical indications for admission to inpatient care may include patients with 1 or more of the following:  Acute cholangitis as indicated by ALL of the following: Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L (milligrams per liter), ...  Evidence of common bile duct disease indicated by 1 or more of the following: Total serum bilirubin level greater than or equal to 2 mg/dL (milligrams per deciliter) (34 micromoles/L (liter)), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), AST or ALT greater than 1.5 times the upper limit of normal, Hepatobiliary imaging showing biliary dilatation or evidence of etiology (e.g., stricture, stone, previously placed stent); Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; ...Calculus or obstruction of gallbladder or bile duct and 1 or more of the following: Hemodynamic instability, Common bile duct obstruction diagnosed (e.g., by imaging), Vomiting that is severe or persistent, Dehydration that is severe or persistent,  Severe pain requiring acute inpatient management,  Bacteremia.

This patient did not need to be admitted as he could have been managed with an outpatient or ambulatory basis. He did not have any indication for acute inpatient admission given that he was afebrile, and the labs were normal with normal liver function tests, and normal bilirubin. His HIDA scan was positive for acute cholecystitis, but he did not need to be kept having an MRCP and could have had a lap cholecystectomy and sent home the same day.

The admission was not justified at the inpatient admission level as the patient should have been managed in an observation setting.  The health care plan did act reasonably and with sound medical judgment.

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

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


Answer: The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents.

Answer:
Diagnosis: Chronic Migraine.
Treatment: Botox Injection.

Answer: The patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination.

Answer: At issue is the medical necessity of a Botox injection.

Context:
Diagnosis: Chronic Migraine.
Treatment: Botox Injection.

The insurer denied the Botox injection.
The determination is upheld.

The patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination.
At issue is the medical necessity of a Botox injection.

The requested health service/treatment of Botox Injection is not medically necessary for this patient. While Botox is Food and Drug Administration (FDA) approved for the prevention of chronic migraine, the submitted documentation does not show that the patient has undergone an adequate trial of preventative agents. The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents. Not all hypertensive agents or antidepressants are effective for prevention of migraine. There is no specification of what drugs were tried and failed or the duration of therapy.

Additionally, there is documentation that the patient has a headache on 15 days of the month. Chronic migraine is defined as 15 or more headache days per month with 8 or more of those days meeting migraine criteria for at least 3 months. There is inadequate documentation of chronic migraine.

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


Answer: The patient had a post-tonsillectomy bleed.

Answer: Diagnosis: Post-tonsillectomy bleed

Answer: Treatment: Inpatient Hospital Stay

Answer: The insurer denied the Inpatient Hospital Stay.

Answer: The patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.

Answer:
She was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.
At issue is the medical necessity of an inpatient stay.

Context:
Diagnosis: Post-tonsillectomy bleed
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.
She was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary for this patient.
The patient had a post-tonsillectomy bleed. It is considered standard of care to admit a young child for observation when there is evidence of bleeding because children have overall low blood volumes and excessive bleeding can lead to significant medical complications. Based on the clinical documents the child was not actively bleeding, had normal vital signs and was in no cardiopulmonary distress. It would be considered clinically appropriate and standard of care to observe the child overnight. However, the care could have been provided at a lower level than inpatient.

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