Answer: The patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion.

Answer: Diagnosis: Chronic lung disease

Answer: Treatment: Pulmozyme

Answer: The insurer is denied coverage for Pulmozyme.

Answer: The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.

Answer: this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits.

Context:
Diagnosis: Chronic lung disease

Treatment: Pulmozyme

The insurer is denied coverage for Pulmozyme. The denial is upheld.

The patient is a female who was born following a premature birth at over 30 weeks gestation.  The patient's history was significant for Pierre-Robin syndrome, seizures, developmental delay, scoliosis, dysphagia and chronic aspiration from sialorrhea. The patient had chronic lung disease and required Bilevel Positive Airway Pressure (BIPAP) when sleeping and had episodes of low oxygen saturations. The patient was treated with cough assist and Vest daily.  The patient had been treated with hypertonic saline, albuterol and Pulmozyme which the patient had been receiving twice a day for. The medical record indicates that this patient was at risk of prolonged hospitalizations prior to starting Pulmozyme and based on the impression of the patient's mother and the treating physician, the patient's respiratory condition improved on Pulmozyme.  The patient's mother indicated that the patient had clinically worsened since this patient's Pulmozyme was discontinued coverage by her insurance. The patient had been requiring additional chest physical therapy because of increased chest congestion and episodes of oxygen desaturation. The patient was seen and was not seen for a visit again until several months after.  The medical record notes that the patient had not required any Emergency Room (ER) visits or hospitalizations and she had only a few upper respiratory infection (URI) illnesses in the winter. The patient only required one course of antibiotics and treatment with 3 liters of oxygen on one occasion.

Based on the review of the medical record and literature, Pulmozyme (dornase alfa) is not medically necessary. The patient had a complicated history of chronic lung disease and aspiration pneumonia and required airway clearance treatments on a daily basis.  There was no indication that the patient produced purulent sputum or had chronic bacterial lung infection.  There had not been a computed tomography (CT) scan or chest x-ray to document the presence of atelectasis or bronchiectasis.  The patient had not required a bronchoscopy.  In addition the medical record indicates that this patient had been stable over several months with no hospitalizations or Emergency Room (ER) visits.  The medical history does not support the need for ongoing daily therapy with Pulmozyme twice daily (BID) at home.  It is not the standard of care to prescribe Pulmozyme for lung disease related to chronic aspiration in the absence of persistent bacterial bronchitis, bronchiectasis and purulent sputum.

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

The carrier's denial of coverage for Pulmozyme should be upheld.  The medical necessity is not substantiated.

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


Answer: This patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice.

Answer: This patient presented with mild alcohol withdrawal with a CIWA of 9

Answer: It is noted

Answer: that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice.

Context:
Substance Abuse
Inpatient Hospital Stay

This patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice. The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary. This patient presented with mild alcohol withdrawal with a CIWA of 9 in the setting of no known prior history of seizures or delirium tremens during withdrawal. It was reasonable to observe the patient on the medical unit at a lower level of care with CIWA protocol, IV fluids, thiamine and folate, and observation for the development of new symptoms such as changes in mental status. It is noted, however, that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice. It is unclear why this patient with concerns for mild alcohol withdrawal, CIWA scores of 9-15 with a normal mental status, no reports of ongoing nausea or vomiting, and without any other concurrent medical issue, required care at the inpatient level of care and could not have been safely treated at a lower level.

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


Answer: This is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation.

Answer: Diagnosis: Abdominal Pain.

Answer: Treatment: Inpatient stay.

Answer: The insurer denied the inpatient stay.

Answer: This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis

Answer: The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day.

Context:
Digestive System/Gastrointestinal.
Inpatient Hospital.

Diagnosis: Abdominal Pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld.

This is the case of a child who presented to the emergency department (ED) with a 2 day history of abdominal pain. The location of pain was right lower quadrant (RLQ), and additional symptoms included anorexia. There was no fever, cough, sore throat, or vomiting. The patient was seen by the primary care physician (or provider) (PCP) who gave Zofran and sent her to the ED for further evaluation.

The inpatient hospitalization was not medically necessary. This patient was brought to the ED for evaluation of abdominal pain. There was initial concern for appendicitis, but the ED work-up was non diagnostic. The patient's condition improved while in the ED and vital signs remained stable. He was admitted to the inpatient unit for overnight observation and re-evaluation. He was discharged home the following day. His care was appropriate for a lower level. The inpatient level of care was not medically necessary.

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


Answer: Diagnosis: Deep Vein Thrombosis

Answer: Treatment: Inpatient admission

Answer: The insurer is denied coverage for inpatient admission.

Answer: This patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus.

Answer: This is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology.

Context:
Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.
The denial is overturned.
This is a male patient with a medical history of coronary artery disease (CAD), hyperlipidemia, hypertension, prior myocardial infarction (MI) and cardiovascular accident (CVA), depression, pneumonia, and bilateral lower extremity weakness. The patient presented to the Emergency Department (ED) with complaints of chest pain and leg pain. The patient described the chest pain as left-sided, sharp, stabbing, worse with smoking cigarettes, worse with cough and worse with exertion. These episodes were reported to be intermittent and last several hours at a time. The patient denied shortness of breath, lightheadedness, dizziness, headache and abdominal pain. The patient's echocardiogram was done that showed normal left ventricular ejection fraction (LVEF). The patient reported previous neuropathic leg pain; he ran out of gabapentin last week. The patient's presenting vital signs were: blood pressure (BP) 152/87, pulse 51, temperature 97.8, respirations 20, oxygen saturation 99% and BMI 34.99. The patient's physical exam noted bilateral lower extremity swelling the left being greater than the right. The patient's laboratory results included sodium 140, potassium 5.0, BUN 10, and creatinine 0.8, an initial troponin was less than 0.012. The patient's electrocardiogram (EKG) revealed sinus bradycardia at a heart rate of 49 bpm. There was left anterior fascicular block and there was asymmetrical T-wave inversion in leads III, AVF, V3-V6. These were non-specific repolarization changes. The patient's chest x-ray showed fibrosis at both lung bases. There was no acute pulmonary disease and no change when compared with imaging done. The patient was found to have an acute venous thrombosis of the left bilateral lower extremities. At the time of discharge, the patient was advised to make outpatient appointments with his primary care provider, cardiology and hematology.

This patient with a history of CAD, prior MI, CVA was found to have a pulmonary embolus with lower extremity thrombus. The multiple comorbid conditions along with the presence of PE and lower extremity thrombus argue against outpatient management. Thus, as discussed in Up to Date, while out patient anticoagulation can be used for PE, this assumes carefully selected patients. Most patients are still initially admitted as an inpatient for several days followed by long term outpatient anticoagulation.

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

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.

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


Answer: This patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.

Answer: Diagnosis: Breakthrough seizure

Answer: Treatment: Inpatient admission

Answer: The insurer denied coverage for inpatient admission.

Context:
Diagnosis: Breakthrough seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld.

This patient is a female with a past medical history of asthma, diabetes mellitus, hypertension, and noncompliance with medication for seizure disorder.  The patient was brought to the Emergency Department by the Emergency Medical Services (EMS) with subjective complaints of severe headache, vomiting times approximately 1 hour, and the patient was noted to have left-sided facial droop on EMS arrival.  On arrival at the Emergency Department, the patient was awake and alert and continues to complain of a headache.  The patient stated she had urinated on herself and did not have neck pain or back pain.  The patient denied a fever.  The patient's blood pressure was 167/81 and her heart rate was 95.  The patient underwent imaging studies, which showed no acute pathology.  The patient had an active seizure in the Emergency Department and was treated with Ativan for the seizure.  She also received Keppra while in the Emergency Department.  A stroke was ruled out.  The patient was admitted to the general medical floor with a diagnosis of a breakthrough seizure.  The patient underwent a neurology consultation.  The patient was given a scheduled dose of Keppra and intravenous fluids, along with proton pump inhibitors and antiemetics.  The patient requested and was discharged in stable condition.

Based on MCG guidelines for Seizure, patient meets the criteria for observation care. Patient has an elevated lactate level of 2.3 and requires medication initiation.  Due to the patient's poor social condition (i.e. living in the shelter), medication should be monitored and adjusted with closing monitoring.  While the patient meets the criteria for observation status, patient does not meet the MCG guideline clinical criteria for inpatient admission.  The patient did not have hemodynamic instability or status epilepticus. Whether the patient's focal neurologic deficit (i.e. left facial droop) is new or not is questionable since the patient reported having residual left sided weakness from a stroke several years ago.  The patient's CT of the head and neck ruled out brain disorder or intracranial pathology.

The patient was discharged within 24 hours of being started on scheduled doses of Keppra, which could have been done at the observation setting.  Thus, based on the medical records provided and MCG guideline review, inpatient admission was not medically necessary to treat this patient's medical condition.

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

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

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


Answer: Diagnosis: Hyperkalemia

Answer: Treatment: Inpatient hospital admission

Answer: The insurer denied coverage for inpatient hospital admission.

Answer: This patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.

Answer: She was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban.

Context:
Diagnosis: Hyperkalemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This patient is a woman who had a history of Addison's disease, hyperprolactinemia, pituitary adenoma, anti-phospholipid antibody syndrome with a history of deep vein thrombosis (DVT) and pulmonary embolus, diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease with stent several years ago and depression. She was sent to the Emergency Department (ED) by her Hematologist for a potassium level of 6.2 on laboratory testing; the patient was asymptomatic. Initial vital signs including a blood pressure of 98/69, a heart rate of 77, a temperature 97.4F, a respiratory rate of 18, and an oxygen saturation on room air of 98%. An EKG revealed peaked T waves, but was otherwise unremarkable. Laboratory test results included a white blood cell (WBC) count of 8.0, a hemoglobin of 10.9, a creatinine of 1.2, a glucose of 213, a sodium of 136, a potassium of 6.2, a chloride of 110, a bicarbonate of 16, and a troponin <0.012. She was treated with Kayexalate, intravenous fluids, calcium gluconate, and insulin and had an episode of nausea and vomiting while taking the Kayexalate.

She was seen by a Hematologist who raised the issue of possible type 4 renal tubular acidosis and by an Endocrinology consultant who felt that medication compliance may have played a role. Psychiatry did not feel that she was actively depressed. She was discharged on stress doses of steroids tapered back to her maintenance doses of Florinef and hydrocortisone over a week, as well as on her other medications, which included aspirin, atorvastatin Linzess, Trulicity, bupropion, Cabergoline, Lexapro, Lantis, Novolog, metformin, metoprolol, Protonix and rivaroxaban.

There is no evidence that this patient required an acute inpatient level of care to evaluate or treat her newly noted potassium level of 6.2, which was asymptomatic, with no evidence for conduction abnormalities or arrhythmias. In addition, she did not have conditions that could contribute to a continued acute rise in potassium levels such as worsening renal function, rhabdomyolysis or significant gastrointestinal bleeding. The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The denial of the inpatient hospital admission is upheld because there is no evidence that this patient was at risk for short term adverse cardiovascular events, based on her clinical presentation and results of testing and treatment performed in the Emergency Department.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.

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


Answer: This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces.

Context:
This is a patient with a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, moderate overbite and moderate overjet. The proposed treatment is braces.

The health plan's detrmination is upheld.
The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this case.

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


Answer: This patient is a female who presented to emergency department.  The patient had a past medical history of congenital severe communicating hydrocephalus, orthostatic hypotension.  The patient had a history of recurrent falls usually without loss of consciousness.  The patient had a temperature 99.2 with a heart rate of 114, respirations 16, oxygen saturation 98% and blood pressure 120/78.  The patient complained of 4/10 pain to lower back and head.  The patient had a Glasgow coma scale score of 15.  The patient had a fall 1 hour prior to admission.  The patient denied any dizziness/lightheadedness prior to fall.  The patient stated that she woke up and was on the floor.  The patient complained of posterior head pain and lower back pain.  Examination showed right-sided temporal contusion.  There was bruising to left lower extremity.  The patient had a white blood cell count of 13, red blood cell count 4.14, hemoglobin 13, hematocrit 29.4, platelets 206.  CT the head revealed stable chronic severe communicate and hydrocephalus.  There was no shift of the midline structures, mass-effect, hemorrhage or other issues.  There was no evidence of acute infarction.  Chest x-ray was negative.  X-ray of the pelvis was negative.  An EEG showed no seizures.  The patient refused physical rehabilitation and was discharged.

Answer: Diagnosis: Falls; congenital severe communicating hydrocephalus

Answer: Treatment: Inpatient Admission

Answer: The insurer denied coverage for Inpatient Admission.

Answer: The documentation indicated that the patient did have a fall with a loss of consciousness.  There was no postictal state following the fall.  The patient had imaging studies that showed no evidence of significant findings.  A CAT scan showed no shift of midline structures, mass-effect or hemorrhage.  EEG showed no seizures.

Context:
Diagnosis: Falls; congenital severe communicating hydrocephalus

Treatment: Inpatient Admission

The insurer denied coverage for Inpatient Admission. The denial was upheld.

This patient is a female who presented to emergency department.  The patient had a past medical history of congenital severe communicating hydrocephalus, orthostatic hypotension.  The patient had a history of recurrent falls usually without loss of consciousness.  The patient had a temperature 99.2 with a heart rate of 114, respirations 16, oxygen saturation 98% and blood pressure 120/78.  The patient complained of 4/10 pain to lower back and head.  The patient had a Glasgow coma scale score of 15.  The patient had a fall 1 hour prior to admission.  The patient denied any dizziness/lightheadedness prior to fall.  The patient stated that she woke up and was on the floor.  The patient complained of posterior head pain and lower back pain.  Examination showed right-sided temporal contusion.  There was bruising to left lower extremity.  The patient had a white blood cell count of 13, red blood cell count 4.14, hemoglobin 13, hematocrit 29.4, platelets 206.  CT the head revealed stable chronic severe communicate and hydrocephalus.  There was no shift of the midline structures, mass-effect, hemorrhage or other issues.  There was no evidence of acute infarction.  Chest x-ray was negative.  X-ray of the pelvis was negative.  An EEG showed no seizures.  The patient refused physical rehabilitation and was discharged.
The medical literature indicates that inpatient admission is indicated for patients with hemodynamic instability, altered mental status is severe persistent, diagnosis requiring inpatient admission, cardiac disease or finding that indicates necessity of immediate intervention, cardiac ischemia, sustained or symptomatic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response pacemaker malfunction, inheritable cardiovascular condition predisposing to arrhythmias diagnosed or suspected dehydration that is severe persistent, syncope causing injury requiring hospitalization or continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive or antiarrhythmic medication needed.
The documentation indicated that the patient did have a fall with a loss of consciousness.  There was no postictal state following the fall.  The patient had imaging studies that showed no evidence of significant findings.  A CAT scan showed no shift of midline structures, mass-effect or hemorrhage.  EEG showed no seizures.  There was no evidence of hemodynamic instability, altered mental status that was severe persistent, diagnosis requiring inpatient admission, cardiac ischemia, sustained or symptom medic ventricular tachycardia, symptomatic conduction system disease, bradycardia or sinus pauses, supraventricular tachycardia, atrial fibrillation with rapid ventricular response, pacemaker malfunction, dehydration that was severe persistent or syncope causing injury requiring hospitalization.  Therefore, the patient's condition was appropriate for level of observational care rather than inpatient level care.  As such, the inpatient admission was not medically necessary.

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

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


Answer: This is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh.

Answer: The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient.

Context:
Burns
Inpatient hospital stay

This is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh. The health plan's determination of medical necessity is overturned in whole. The best interest of this patient is an inpatient admission. The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient. According to the International Society for Burn Injury guidelines, any third degree burn necessitates a transfer to a burn center. Besides meeting standard practices for medical necessity, this case also meets McKesson InterQual criteria for acute adult: burns. This case qualifies with 3rd degree burns with 2-5% TBSA and need for complex burn care.

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


Answer: Diagnosis: Muscle weakness, Normal pressure hydrocephalus, Peripheral arterial occlusive disease

Answer: Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week

Answer: The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week.

Answer: This is a female with a medical history of uncontrolled Type ll diabetes mellitus, aortic valve disorder, peripheral arterial occlusive disease, muscle weakness, congestive heart failure, sepsis, diabetic polyneuropathy, chronic obstructive lung disease, chronic kidney disease stage 3, cerebrovascular accident, anemia, migraine and normal pressure hydrocephalus. She has been receiving Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week. The patient requested an increase of CDPAS to 84 hours per week, which was denied by the insurer.

Answer: Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent for housekeeping tasks; needs maximal assistance for meal preparation and shopping; extensive assistance for stairs and medications. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing and limited assistance for all other ADLs, except bed mobility (setup help). The UAS indicates the patient's decision making for daily tasks is modified independence (some difficulty in new situations). The patient needs extensive assistance with finances and medications

Answer: This patient has an extensive medical history associated with various symptoms causing decreased functional ability with daily activities

Answer: The patient's daughter was able to provide assistance; however, the daughter is currently working and unable to continue providing informal care. The UAS identified a second informal caregiver. There is no current information on the availability of the other caregiver.

Context:
Diagnosis: Muscle weakness, Normal pressure hydrocephalus, Peripheral arterial occlusive disease

Treatment: Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS), 7 days per week, 12 hours per day; 84 hours per week.

The denial is overturned.

This is a female with a medical history of uncontrolled Type ll diabetes mellitus, aortic valve disorder, peripheral arterial occlusive disease, muscle weakness, congestive heart failure, sepsis, diabetic polyneuropathy, chronic obstructive lung disease, chronic kidney disease stage 3, cerebrovascular accident, anemia, migraine and normal pressure hydrocephalus. She has been receiving Consumer Directed Personal Assistance Service (CDPAS) 35 hours per week. The patient requested an increase of CDPAS to 84 hours per week, which was denied by the insurer.

Uniform Assessment System (UAS) documentation indicates that the patient is totally dependent for housekeeping tasks; needs maximal assistance for meal preparation and shopping; extensive assistance for stairs and medications. For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing and limited assistance for all other ADLs, except bed mobility (setup help). The UAS indicates the patient's decision making for daily tasks is modified independence (some difficulty in new situations). The patient needs extensive assistance with finances and medications, which can suggest some cognitive deficits. Overall, it does not appear that cognitive impairment is a major contributing factor to the patient's functional impairment with most daily tasks. The patient's physical limitations are most likely the primary cause of the patient's need for assistance with most daily activities.

This patient has an extensive medical history associated with various symptoms causing decreased functional ability with daily activities Considering the patient's medical conditions and functional impairment, it is medically necessary and in the patient's best interest to have a caregiver present throughout the day to provide assistance with household related tasks and ADLs. The patient's daughter was able to provide assistance; however, the daughter is currently working and unable to continue providing informal care. The UAS identified a second informal caregiver. There is no current information on the availability of the other caregiver. Considering the request for additional service is for 84 CDPAS hours per week, it is reasonable to conclude that there are no informal caregivers who can provide care for that amount of hours per week. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. When informal caregivers are unavailable for personal care assistance on a regular basis, then personal care services are indicated to provide necessary assistance with daily activities as needed throughout the day.

CDPAS 12 hours per day can adequately accommodate all instrumental activities of daily living (IADLs) and ADLs that are done on a routine basis each day.  However, the patient needs assistance with toileting, incontinence care and mobility around her home (transfers, walking). It is unclear how the patient will have assistance for these unscheduled activities when they occur at times when the aide is not present. It is not known whether there is a plan for informal caregivers to provide assistance when the aide is not present. Re-assessment will determine if further modification of the plan is needed to meet the patient's personal care needs.

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

Based on the above, the medical necessity for CDPAS, 7 days per week, 12 hours per day; 84 hours per week is substantiated. The insurer's denial is overturned.

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


Answer: The patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture.

Answer: The patient has a complicated past medical history.

Answer: The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment

Answer: Multiple providers who care for the patient documented medical necessity to increase PCW service hours.

Answer: Diagnosis: Gastrointestinal and Liver Cancer.

Answer: Treatment: Home Health Care.

Answer: The insurer denied the requested health service/treatment of Increase in Personal Care Worker hours.

Context:
Diagnosis: Gastrointestinal and Liver Cancer.
Treatment: Home Health Care.
The insurer denied the requested health service/treatment of Increase in Personal Care Worker hours.

The health plan determination is overturned.

The patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture.

The increase in personal care worker (PCW) service to 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient.

The patient has a complicated past medical history. The PCW is medically necessary for helping the patient to transport and attend the medical appointments and tests. The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment, making her assistance needs for tasks of stairs, walking, locomotion, and toilet use higher than assessed. PCW service hours are not solely for supervision and safety but for assisting the patient with ADL's and IADL's. Multiple providers who care for the patient documented medical necessity to increase PCW service hours. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the home, which is the case for this patient.

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


Answer:
The patient is a female with neck pain and migraine headaches that has previously
had cooled radiofrequency ablation (c-RFA) with near 100% relief for almost one
year.

Answer: the patient has previously undergone this procedure with near 100% relief for about a year.

Answer: Diagnosis:  Neck pain and migraines.

Answer: Treatment:  Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.

Answer: The insurer denied the Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.

Answer:
This patient has chronic low back pain with facet arthropathy.  The patient has had
two diagnostic medial branch blocks and previously had radiofrequency ablation (RFA) with excellent results.

Context:
Diagnosis:  Neck pain and migraines.
Treatment:  Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.

The insurer denied the Surgery - 64633-RT and 64634-RT (cooled radiofrequency neuroablation), Pre-service.  The denial is overturned.

The patient is a female with neck pain and migraine headaches that has previously
had cooled radiofrequency ablation (c-RFA) with near 100% relief for almost one
year.

Yes, the proposed cooled radiofrequency neuroablation (64633-RT and 64634-RT) is medically necessary.

The requested cooled radiofrequency ablation (c-RFA) is medically necessary.  The procedure uses the same code as thermal radiofrequency ablation (t-RFA), often referred to as conventional radiofrequency ablation (RFA).  The temperature for cooled radiofrequency ablation (c-RFA) is above 60 degrees Celsius, which is often the temperature used in a thermal radiofrequency ablation (t-RFA).  Many of
the original articles on radiofrequency ablation (RFA) cite 60 degrees for ablation.  In addition, the tissue temperature has been shown to be 80 degrees.  Cooled radiofrequency ablation (c-RFA) is not to be confused with pulsed radiofrequency
ablation (RFA), where the temperature is below 42 degrees.  Neural ablation has
been shown to occur at 42 degrees Celsius.  Therefore, any temperature about 42 is
a thermal lesion.  Studies have shown conventional radiofrequency ablation (c-RFA) to be as effective as thermal radiofrequency ablation (t-RFA).

Studies have shown conventional radiofrequency ablation (c-RFA) to as effective as t-RFA.  It poses no increased risk and is an alternative to thermal radiofrequency ablation (t-RFA).  The distinction between the two is primarily due to proprietary technology.  No study has shown it to be inferior to  thermal radiofrequency ablation (t-RFA), and its
indications are same for thermal radiofrequency ablation (t-RFA).  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used.

This patient has chronic low back pain with facet arthropathy.  The patient has had
two diagnostic medial branch blocks and previously had radiofrequency ablation (RFA) with excellent results.  Therefore, the criteria according to the Spine Intervention Society has been met, and this is medically necessary and standard of care.  In essence, there is no distinction, and it can be used in all settings that  thermal radiofrequency ablation (t-RFA) can be used.  In addition, the patient has previously undergone this procedure with near 100% relief for about a year.  Given the above, the requested conventional radiofrequency ablation (c-RFA) is medically necessary.

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


Answer: The patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.

Answer: The patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues.

Answer: She has used this medication in the past with good results.

Answer:
Diagnosis: Neuropathic pain
Treatment: Lidocaine Patch

Answer: The insurer denied the Lidocaine Patch.

Context:
Diagnosis: Neuropathic pain
Treatment: Lidocaine Patch
The insurer denied the Lidocaine Patch.
The denial is overturned.

The patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.

Yes, the treatment with Lidocaine 5% patch is medically necessary.

The patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues. Chronic opiates are generally not recommended. She has used this medication in the past with good results. Lidocaine patches have been shown to be effective in the treatment of chronic low back pain in the literature. It is the least invasive option, and it tends to have low side effects.  She has tried lidocaine jelly, but she develops a rash. The options are limited. Given the above, the requested lidocaine patches are medically necessary,

The risks of the alternatives far outweigh the benefits. The patient has failed most conventional and common modalities.

Lidocaine patches have been used for numerous pain complaints outside of PHN (postherpetic neuralgia), including low back pain. This has been shown in the literature, and is considered standard of care in the treatment of many pain complaints aside from PHN.

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


Answer: This is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.

Answer: Diagnosis:  Iritis.

Answer: Treatment:  BromSite 0.075% Ophthalmic Solution.

Answer: The insurer denied coverage for BromSite 0.075% Ophthalmic Solution.

Context:
Diagnosis:  Iritis.
Treatment:  BromSite 0.075% Ophthalmic Solution.

The insurer denied coverage for BromSite 0.075% Ophthalmic Solution.  The denial is upheld.

This is a male patient with a history of chronic iritis in the right eye.  The patient's visual acuities are 20/40 in the right eye (OD) and 20/20 in the left eye (OS).  The patient has diagnoses of posterior capsular opacification OD, dry eye and status post retinal detachment repair OD.  The patient's treating physician noted that BromSite is used to treat chronic iritis in the right eye, and BromSite will be used to stabilize and alleviate the patient's symptoms due to iritis.  The physician also noted that the patient has used Ketorolac 0.5% in the past with no success and is currently using Bromfenac, but the patient states this does not seem to be as effective as BromSite.  It was noted that the patient has used BromSite in the past with great success.

Based on the review of the patient's medical record and literature, the requested medication, BromSite (bromfenac) 0.075% ophthalmic solution is not considered medically necessary for this patient.  The patient has not tried available formulary alternatives (i.e., flurbiprofen), or has not demonstrated contraindications to use of alternatives.  The literature does not support that BromSite is superior in efficacy or tolerability compared to other topical nonsteroidal anti-inflammatory drug (NSAID)-based ophthalmic drops.

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

Based on the above, the medical necessity for BromSite 0.075% Ophthalmic Solution is not substantiated.  The insurer's denial should be upheld.

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


Answer: This is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.

Answer: Diagnosis: Hypertensive emergency.

Answer: Treatment: Full hospital admission.

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

Context:
Diagnosis: Hypertensive emergency.

Treatment: Full hospital admission.

The insurer denied coverage for the full hospital admission.

The denial is overturned.

This is a male patient who was admitted with hypertensive emergency which is indicated by a systolic blood pressure (SBP) greater than 180 or diastolic blood pressure (DBP) greater than 120 with evidence of acute or worsening target organ damage. The patient's blood pressure was 261/147, and he presented with signs of myocardial infarction including elevated troponin and electrocardiogram (EKG) changes. The patient also had acute kidney injury (AKI) noted with elevated creatinine from a baseline of 2.2 up to 4.7. The patient's condition required close cardiac monitoring in the Coronary Care Unit (CCU) and required intravenous (IV) Cardene drip and adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure.

Based on the review of the medical record and literature, the full hospital admission was medically necessary for this patient. The patient's medical condition required an extended stay after blood pressure control due to his worsening kidney function and possible need for renal replacement therapy. Thus, the inpatient admission was appropriate and consistent with the standard of care.

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

Based on the above, the medical necessity for the full hospital admission is substantiated. The insurer's denial should be overturned.

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


Answer: The patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.

Answer: The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.

Answer: The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.

Answer: Diagnosis:  Spastic quadriplegic cerebral palsy.

Answer: Treatment:  Gait Trainer.

Answer: The health plan denied the Gait Trainer.

Context:
Diagnosis:  Spastic quadriplegic cerebral palsy.
Treatment:  Gait Trainer.

The health plan denied the Gait Trainer.  The determination is upheld.

The patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.

The requested gait trainer is not medically necessary for this patient.  The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  There are not sufficient benefits of the use of a gait trainer in patients with cerebral palsy supported by medical literature to warrant it as a medically necessary device.  A Cochrane Review of Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy found that there was a lack of evidence to support significant benefits.  In this review, comparison with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support).  However this was not definite.  Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function.  The lack of supportive medical evidence of significant benefit and outcomes for gait trainer in patients with cerebral palsy means this device cannot be considered medically necessary, even if it is useful for the patient.  The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.  Gait trainer devices can be usable by patients and yet not be medically necessary.  The patient's possession of and ability to use a gait trainer in the past does not alter the lack of evidence that such a device is medically necessary

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


Answer: Diagnosis: Shortness of breath, lower abdominal pain, vaginal bleeding

Answer: Treatment: Inpatient admission

Answer: The insurer denied the inpatient admission.

Answer: The patient is a female with a history of iron deficiency anemia and uterine fibroids who presented to the Emergency Department (ED) for an emergency evaluation due to shortness of breath, palpitations for a day, chills and fever, lower abdominal cramping, rash, and vaginal bleeding for two to three days. The patient reported a recent history (one week ago) of uterine fibroid embolization. The patient reported that she was discharged after the procedure with Toradol, gabapentin, Tylenol, tramadol, levofloxacin, Zofran, Prilosec and senna.

Answer: On initial presentation, the patient was febrile (temperature of 100.6 degrees Fahrenheit), blood pressure (BP) was 124/88, pulse was 82 beats per minute (she was later tachycardic at 104), and respirations were 20 breaths per minute. On examination, the patient looked ill, with tachycardia, suprapubic tenderness to palpation, erythema/bleeding of vagina, enlarged uterus, submandibular lymphadenopathy, and bilateral upper and lower extremity morbilliform urticarial rash. Laboratory studies were remarkable for leukocytosis, microcytic anemia, thrombocytosis, eosinophilia, transaminitis (aspartate aminotransferase [AST] / alanine aminotransferase [ALT] 353/335), and proteinuria.

Answer: In the emergency department, the patient was administered Benadryl and steroids.  The treating physician's clinical impression was emergently concerned for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome secondary to gabapentin, levofloxacin or Toradol.  For management of DRESS syndrome, the patient was kept on intravenous (IV) Benadryl and intravenous (IV) Prednisone.  Although patient was advised to stay in the hospital, the patient decided to leave the hospital against medical advice. The patient was sent home (against medical advice) with prednisone, Augmentin and recommendations to follow up with gynecology (GYN) and her primary care physician (PCP).

Answer: This patient presented with elevated temperature, lymphadenopathy, elevated liver enzymes, and eosinophilia a week after a uterine artery embolization.

Answer: the patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

Context:
Diagnosis: Shortness of breath, lower abdominal pain, vaginal bleeding
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with a history of iron deficiency anemia and uterine fibroids who presented to the Emergency Department (ED) for an emergency evaluation due to shortness of breath, palpitations for a day, chills and fever, lower abdominal cramping, rash, and vaginal bleeding for two to three days. The patient reported a recent history (one week ago) of uterine fibroid embolization. The patient reported that she was discharged after the procedure with Toradol, gabapentin, Tylenol, tramadol, levofloxacin, Zofran, Prilosec and senna.

On initial presentation, the patient was febrile (temperature of 100.6 degrees Fahrenheit), blood pressure (BP) was 124/88, pulse was 82 beats per minute (she was later tachycardic at 104), and respirations were 20 breaths per minute. On examination, the patient looked ill, with tachycardia, suprapubic tenderness to palpation, erythema/bleeding of vagina, enlarged uterus, submandibular lymphadenopathy, and bilateral upper and lower extremity morbilliform urticarial rash. Laboratory studies were remarkable for leukocytosis, microcytic anemia, thrombocytosis, eosinophilia, transaminitis (aspartate aminotransferase [AST] / alanine aminotransferase [ALT] 353/335), and proteinuria.

In the emergency department, the patient was administered Benadryl and steroids.  The treating physician's clinical impression was emergently concerned for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome secondary to gabapentin, levofloxacin or Toradol.  For management of DRESS syndrome, the patient was kept on intravenous (IV) Benadryl and intravenous (IV) Prednisone.  Although patient was advised to stay in the hospital, the patient decided to leave the hospital against medical advice. The patient was sent home (against medical advice) with prednisone, Augmentin and recommendations to follow up with gynecology (GYN) and her primary care physician (PCP).

Yes, the inpatient admission was medically necessary.

This patient presented with elevated temperature, lymphadenopathy, elevated liver enzymes, and eosinophilia a week after a uterine artery embolization.  Common complications of uterine artery embolization include pelvic pain, fever, and vaginal discharge, but these are self-limiting in most patients.  The most serious potential complications are introduction of embolic agents into inadvertent vessels, necrosis of the gluteus maximus or limb, or pulmonary embolism. However, the patient was diagnosed with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life-threatening drug-induced hypersensitivity reaction that includes skin eruption, hematologic abnormalities (eosinophilia, atypical lymphocytosis), lymphadenopathy, and/or internal organ involvement (liver, kidney, lung). The diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) is based upon the combination of clinical features (history of drug exposure, cutaneous findings, systemic findings, such as fever, lymphadenopathy, and visceral involvement) and laboratory findings. Identification and prompt withdrawal of the offending drug is the mainstay of treatment for patients with drug reaction with eosinophilia and systemic symptoms (DRESS). Serial biochemical measurements should be performed to monitor liver function. Severe hepatocellular injury may evolve to acute liver failure and the only effective therapy may be liver transplantation.  It is obvious from the above that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a very serious condition.

It is obvious from the above, that drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious condition and quick and adequate management is medically necessary. In this patient's case, admission for intravenous (IV) steroids was medically necessary to monitor for any possible worsening of her situation, to investigate which drug was the offending one and to rule out any other possible etiology for her symptoms.

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


Answer: The patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.

Answer: Diagnosis: osteoarthritis

Answer: Treatment: Personal Care Worker (PCW) Service

Answer: The insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day.

Answer: The patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver

Answer: The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion.

Context:
Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: osteoarthritis
Treatment: Personal Care Worker (PCW) Service
The insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day. The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.

The Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day is medically necessary for this patient.
The patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver, although the insurer incorrectly assumed the patient continued to have informal caregiver. The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion. The assessment tool performed over the phone also underestimated the patient's ADL and IADL assistance needs for tasks of meal preparation, personal hygiene, dressing upper/lower body, walking, locomotion, toileting, transfer toilet, and eating. The PCA service hours are not solely for safety and supervision but to assist the patient with successful completion of ADL and IADL tasks. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. The requested PCA services 8 hours/day, 7 days/week are medically necessary for this patient.

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


Answer: The patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.

Answer: He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.

Answer: Diagnosis:  Dental Disorder.

Answer: Treatment:  Braces and Monthly Visits.

Answer: The insurer denied Braces and Monthly Visits.

Answer: The patient does have maxillary and mandibular crowding

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

The insurer denied Braces and Monthly Visits.  The determination is upheld.

The patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is not medically necessary for the patient at this time.  He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.  Research indicates the following risk factors for impacted canines in patients over 10 years of age (2):  1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side (The patient does not have this, as shown in the panoramic radiograph), 2) The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption), 3) The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors), and 4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided).

While that study shows risk factors for impacted maxillary canines, there is nothing in this panoramic radiograph to suggest that tooth #22 will be unable to erupt.  Studies show that impacted mandibular canines are rare (3), and none of the records support a diagnosis requiring treatment at this time.  The patient does have maxillary and mandibular crowding; however, the patient does not exhibit any of the criteria to suspect that the canine is impacted.  Therefore, orthodontic treatment is not medically necessary.

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


Answer: Diagnosis: Spinal Muscular Atrophy

Answer: Treatment: Evrysdi SGM

Answer: The health plan denied the requested prescription drug.

Answer: A review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.

Answer: An office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.

Answer:
The reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).
A letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice.

Context:
Diagnosis: Spinal Muscular Atrophy
Treatment: Evrysdi SGM
The health plan denied the requested prescription drug.
The health plan's determination is upheld.

A review of the prior authorization request indicated a diagnosis of spinal muscular atrophy type 2. The patient was not dependent on any invasive ventilation or noninvasive ventilation (though other notes indicate that he was using bi-level positive airway pressure (BiPAP)). The medication was prescribed by or in consultation with a physician specializing in the treatment of spinal muscular atrophy. The patient is not currently undergoing treatment with Evrysdi. The diagnosis of spinal muscular atrophy was confirmed with genetic testing. The patient has three copies of (genetic proteins= survival motor neuron (SMN) SMN2 and 0 copies of SMN1.
The patient did not undergo a Hammersmith Infant Neurological Exam, Part 2, Hammersmith Functional Motor Scale Expanded (HFMSE), Children's Hospital of Philadelphia infant test of neuromuscular disorders or Motor Function Measure - 32 items (MFM-32). The patient's age and initiation of the request is not documented.
An office note indicates that the patient did have BiPAP dependence. He is using BiPAP at night with classicist daily. He was undergoing a home physical and occupational therapy. He required a G-tube (gastrostomy tube) for feeding. He was receiving Spinraza. It was noted that the patient had spinal muscular atrophy type 2 and had a stable motor assessment despite complaints of weakness in the arm that was attributed to a delay in Spinraza dosing. A change to Evrysdi was planned.
The reason for denial on prior review as per communications from CVS Caremark is that the patient did not undergo a Hammersmith infant neurologic exam, part two (HIN2), Hammersmith functional motor scale expanded, Children's Hospital of Philadelphia infant test of neuromuscular disorders (CHOP-INTEND or MFM32).
A letter of medical necessity dated indicated that he had been treated with Spinraza but had a decline in function. His physician recommended Evrysdi. He indicated that the HIN2 and CHOP-INTEND would not be appropriate, that HFMSC could not be performed, and that the MFM 32 was not routinely used in clinical practice.

The health plan's determination of medical necessity is upheld, in whole.

No. Evrysdi SGM is an oral medication used to treat spinal muscular atrophy type I. Evrysdi is not medically necessary. In order to determine whether accuracy is effective for the patient, there must be a reproducible documentation of examination findings. It is possible that the physician may not see the patient at every visit. The HFMSC and MFM 32 would be appropriate for these patients. The risk of physical injury with the HFMSC is low. There is no rationale why the physician cannot perform these simple tests or derive a score from his existing examination. The patient would be most properly monitored with the use of these of one of the scales, and, in its absence, response or lack of response cannot be monitored and the requested medication would therefore not be considered medically necessary.

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


Answer: This is a male patient with past medical history of hypertension (HTN). He presented to the emergency department (ED) with complaints of abdominal/epigastric pain, fever and nausea and vomiting for a couple of days. The pain radiated to the right upper quadrant (RUQ). The patient had a sonogram at an urgent care center with findings of gallstones. Exam revealed the abdomen to be soft with RUQ tenderness and Murphy's sign. No guarding or rebound was noted. The patient was afebrile. His white blood cell count was 15.88.  An abdominal ultrasound was performed that showed distended gall bladder containing a calculus. The wall was mildly thickened with a small amount of pericholecystic fluid. There was also a positive sonographic Murphy's sign with the findings compatible with acute cholecystitis. The plan was to admit to surgery and underwent an uneventful laparoscopic cholecystectomy. He was treated with intravenous antibiotics and his diet was advanced as tolerated. He was medically stable and discharged home.

Answer: Diagnosis: Acute Cholecystitis

Answer: Treatment: Inpatient hospital admission

Answer: The insurer denied the inpatient hospital admission.

Context:
Diagnosis: Acute Cholecystitis

Treatment: Inpatient hospital admission

The insurer denied the inpatient hospital admission.

The denial was upheld.

This is a male patient with past medical history of hypertension (HTN). He presented to the emergency department (ED) with complaints of abdominal/epigastric pain, fever and nausea and vomiting for a couple of days. The pain radiated to the right upper quadrant (RUQ). The patient had a sonogram at an urgent care center with findings of gallstones. Exam revealed the abdomen to be soft with RUQ tenderness and Murphy's sign. No guarding or rebound was noted. The patient was afebrile. His white blood cell count was 15.88.  An abdominal ultrasound was performed that showed distended gall bladder containing a calculus. The wall was mildly thickened with a small amount of pericholecystic fluid. There was also a positive sonographic Murphy's sign with the findings compatible with acute cholecystitis. The plan was to admit to surgery and underwent an uneventful laparoscopic cholecystectomy. He was treated with intravenous antibiotics and his diet was advanced as tolerated. He was medically stable and discharged home.

According to MCG Health Inpatient and Surgical care- 24th edition Gall bladder or bile duct inflammation or stone ORG: M-555 (ISC) clinical indications for admission to inpatient care may include patients with 1 or more of the following: 1) 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, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); 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 (34 micromoles/L), Liver function test (alkaline phosphatase (ALP), r-glutamyl transferase (GGT), aspartate aminotransferase (AST), or alanine aminotransferase (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); or  2) Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness; Systemic signs of inflammation indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L); Cholecystectomy not anticipated (i.e., within subsequent few days) due to 1 or more of the following: Finally, MCG Health - Inpatient and Surgical care 24th edition. Cholecystectomy by laparoscopy ORG: S-365 (ISC) noted that  Procedure is indicated for 1 or more of the following: Symptomatic gallstone disease as indicated by ALL of the following: Evidence of gallstone disease as indicated by 1 or more of the following: Stones demonstrated on cholecystography, ultrasound, CT, or MRI, Non-visualizing gallbladder with double-dose cholecystography or HIDA scan, Symptoms of gallstone disease as indicated by 1 or more of the following: Biliary colic; Acute cholecystitis as indicated by ALL of the following: Right upper quadrant pain, mass, or tenderness, Systemic signs of inflammation as indicated by 1 or more of the following: Fever, C-reactive protein level greater than 10 mg/L, White blood cell count greater than 10,000/mm3 (10 x109/L) or less than 4000/mm3 (4 x109/L).

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 inpatient hospital admission is not substantiated.  The insurer's denial is upheld.

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


Answer: Diagnosis: Seizures

Answer: Treatment: Inpatient Hospital

Answer: The health plan denied the inpatient stay.

Answer: The patient is a male who presented to the emergency department after a staring episode.

Answer: He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.

Answer:
He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.
The hospitalization is under review for medical necessity.

Answer: This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office.

Answer: His evaluation included video EEG monitoring

Answer: as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study.

Context:
Diagnosis: Seizures
Treatment: Inpatient Hospital
The health plan denied the inpatient stay.
The health plan's determination is overturned.

The patient is a male who presented to the emergency department after a staring episode.
He was well until approximately a month prior to presentation when he had his first episode of staring. The episodes occurred twice a day and lasted for a few seconds. He did not have any shaking or involuntary movements. He was seen by his primary doctor for his health supervision visit and had an episode of staring during the visit. He was subsequently referred to the emergency department for evaluation of these episodes. His past history was significant for premature birth. Upon presentation he had a temperature of 100 F. His physical examination was normal. Laboratory values were obtained, and he was admitted for evaluation of possible seizures.
He was admitted with seizure precautions and monitoring, with Ativan ordered as needed. A video electroencephalogram (EEG) was obtained as well as a consultation from the neurology team. He did not have staring episodes during the admission, and the video EEG did not show seizure activity. The neurology team also recommended a head magnetic resonance imaging (MRI), and he was given intravenous fluids in preparation for the study. The MRI was normal. He remained stable,  he was felt to be stable for discharge to home with follow up as an outpatient.
The hospitalization is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service of the inpatient stay was medically necessary for this patient. This is a patient who presented with unexplained staring spells. He was referred to the emergency department after one of the events was observed in the primary care physician's office. He required prompt evaluation for possible seizures or other causes of paroxysmal behavior. His evaluation included video EEG monitoring, which needs to be done in an inpatient setting, as well as an MRI study, while monitoring for other possible etiologies and with administration of intravenous fluids in preparation for the study. While typical absence seizures cause staring episodes and are often benign, they typically present at an older age (mean age 6 years). Staring episodes in a can be a sign of a much more serious disorder, including seizures or sepsis, and require prompt evaluation with close monitoring for potential deterioration of clinical status.

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


Answer: Diagnosis: Cardiac/Circulatory.

Answer: Treatment: Inpatient Hospital.

Answer: The insurer denied inpatient stay.

Answer: The patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection.

Answer: In the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.

Answer: This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension.

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

The patient is a male with a history of non-ischemic cardiomyopathy, atrial fibrillation, chronic kidney disease and morbid obesity presented to the emergency department complaining of dyspnea, edema and a 50 pound weight gain over the prior two weeks. He had a left ventricular ejection fraction of 20% and an implanted left ventricular assist device (LVAD). He was on chronic antibiotics for a driveline infection.

In the emergency department, his mean arterial blood pressure (MAP) was 80 millimeters of mercury (mmHg). His heart rate was 70 beats/minute. His respiratory rate was 22/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for abdominal distension and lower extremity edema. The cardiology consultant later noted bibasilar pulmonary rales. Chest x-ray showed mild vascular congestion. The patient was admitted to the hospital with decompensated heart failure. He noted persistent dyspnea. His physical exam showed bibasilar rales and edema. He was treated with high dose intravenous furosemide twice daily. The next day, his dyspnea had improved but he had persistent rales, jugular venous distension and peripheral edema. High dose twice daily intravenous furosemide was continued until it was held after hypotension the night prior; the patient's MAP had fallen to 40 mmHg. His blood pressure was improved and oral diuretics were started. He was discharged. His discharge weight was 50 pounds less than his admission weight. Medical necessity for an inpatient admission is the subject under review.

An inpatient stay was medically necessary for this patient. This patient, with severe left ventricular systolic dysfunction and a left ventricular assist device, presented to the hospital with massive volume overload due to acute decompensated heart failure. He remained volume overloaded despite six days of aggressive intravenous diuresis, which was then complicated by hypotension. He required careful and continuous monitoring of his clinical status, LVAD parameters and laboratory values, along with adjustment of his pharmacologic regimen. This warranted an inpatient level of care.

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


Answer: The patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary.

Answer: Diagnosis: Class I malocclusion.

Answer: Treatment: Braces/monthly visits.

Answer: The insurer denied braces/monthly visits.

Answer: The patient has an

Answer: overbite and overjet.

Answer: there is mild crowding

Answer: The diagnosis states the patient has a skeletal Class I relationship

Context:
Diagnosis: Class I malocclusion.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits.
The health plan's determination is upheld.

The patient in question is a female with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both mildly crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. Braces and monthly visit (x 12) were denied as not medically necessary.

Braces and monthly visit (x 12) are not medically necessary at this time.

The patient has an appropriate overbite and overjet. Yes, there is mild crowding, but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 27 with tooth 6, and the gingival margin of 27 appears to be the same as tooth 22. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.

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


Answer: The patient had past efficacy and no past reported seizures after TMS therapy and is being treated for seizures and has not had one for many years.

Answer: Diagnosis: Major Depressive Disorder.

Answer: Treatment: Transcranial Magnetic Stimulation.

Answer: The insurer denied coverage for Transcranial Magnetic Stimulation.

Answer: This is a male patient who reportedly had depressive symptoms including depressed mood, anhedonia, low energy with difficulty getting out of bed, hopelessness, concentration problems, decreased libido, and he had a diagnosis of Major Depressive Disorder in addition to Generalized Anxiety Disorder. He also had a past reported suicide attempt. The patient had multiple past antidepressant trials without sustained efficacy or with side effects including Fluoxetine, Sertraline, Venlafaxine, Desvenlafaxine, Duloxetine, Fetzima, Viibryd, Trintellix, and Amitriptyline, as well as augmenting medications of Aripiprazole, Rexulti, Quetiapine, Olanzapine, Vraylar, and Lamotrigine. He reportedly had successful transcranial magnetic stimulation (TMS) therapy in the past. He had a history of seizures and takes anti-seizure medications Depakote and Vimpat. The request was for TMS again.

Answer: The insurer denied the request for TMS stating that having a history of seizures is a contraindication for TMS.

Context:
Diagnosis: Major Depressive Disorder.
Treatment: Transcranial Magnetic Stimulation.
The insurer denied coverage for Transcranial Magnetic Stimulation.
The denial is overturned.

This is a male patient who reportedly had depressive symptoms including depressed mood, anhedonia, low energy with difficulty getting out of bed, hopelessness, concentration problems, decreased libido, and he had a diagnosis of Major Depressive Disorder in addition to Generalized Anxiety Disorder. He also had a past reported suicide attempt. The patient had multiple past antidepressant trials without sustained efficacy or with side effects including Fluoxetine, Sertraline, Venlafaxine, Desvenlafaxine, Duloxetine, Fetzima, Viibryd, Trintellix, and Amitriptyline, as well as augmenting medications of Aripiprazole, Rexulti, Quetiapine, Olanzapine, Vraylar, and Lamotrigine. He reportedly had successful transcranial magnetic stimulation (TMS) therapy in the past. He had a history of seizures and takes anti-seizure medications Depakote and Vimpat. The request was for TMS again.

The insurer denied the request for TMS stating that having a history of seizures is a contraindication for TMS. This reviewer disagrees with the decision to deny the request for TMS therapy.

TMS therapy has been cleared by the Food and Drug Administration (FDA) and is indicated for the treatment of Major Depressive Disorder in patients who failed or who did not have satisfactory improvement from 1 past antidepressant medication at or above minimal effective dose and duration in the current episode. In this case this patient had another major depressive episode after reported remission from major depression after past TMS therapy so TMS was considered appropriate and medically necessary treatment again. He reportedly tried and failed multiple classes of antidepressant medication. He reportedly responded to past TMS therapy and had no reported adverse effects and had not reported a seizure for many years as he was being treated with anti-seizure medications.

Stultz and Osburn, state seizures if present are usually self-limiting and that they are rare. They noted that most treatment recommendations are supportive in nature and that the risk of TMS related seizures is less than 1% and that TMS therapy has successfully been used in patients with epilepsy/seizures, traumatic brain injury (TBI), and prior TMS related seizures. They stated that the rate of TMS related seizures was comparable to most psychotropic medications; and they also stated that while having a seizure is a rare adverse effect of TMS, the benefits of treating refractory depression with TMS may outweigh risks of possible adverse effects. The only reported absolute contraindication of TMS is a ferromagnetic metal in the head or neck as epilepsy is considered a relative contraindication and not an absolute contraindication. It was reported that the FDA stated that patients with seizures should be closely monitored when having TMS therapy.

Although the health care plan acted reasonably and with sound clinical judgment, it did not appear that denying TMS was in the best interests of the patient considering the risks of worsened depression and suicide risk. The patient had past efficacy and no past reported seizures after TMS therapy and is being treated for seizures and has not had one for many years. The risk of treatment refractory depression in a patient with current major depressive episodes with a history of a past suicide attempt is higher than the medical risks of potential seizures in a patient being treated for seizures who did not have a past TMS related seizure from his past TMS treatment.

The carrier's denial of coverage for Transcranial Magnetic Stimulation is overturned. The medical necessity is substantiated.

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