Answer: This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery.

Answer: this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain.

Context:
This is a patient who presented to the emergency department (ED) with acute onset abdominal pain, nausea and vomiting (2-days duration).  The past medical history was significant for morbid obesity.  The heart rate at the time of presentation was elevated at 107 beats/minute.  The abdomen was tender and distended.  The white blood cell count (WBC) count was elevated at 13.6 thousand (K).  The patient was evaluated with a computed tomography (CT) scan of the abdomen and pelvis that showed dilated and edematous bowel and mesentery.  The health plan's determination of medical necessity is overturned in whole.
The submitted records support that this patient presented with an acute onset of abdominal pain, nausea and vomiting.  She had a leukocytosis of 13.6 K and pathology identified on a CT scan that indicated possible bowel obstruction.  She was monitored with daily examination and follow up lab assessment.  She underwent a colonoscopy on 12/6/18.  Her condition did gradually improve over 72 hours.  On 12/7/18 she reported less pain and there was improvement with regard to the abdominal pain.  Inpatient admission for the condition of intestinal obstruction was consistent with medical standards, as the period of inpatient confinement was anticipated to last more than 2-days.

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


Answer: This is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis.

Answer: The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis

Context:
Other
Prescription medication

This is a patient with ankylosing hyperostosis (Forestier), site unspecified spondylopathy, unspecified vs. inflammatory disease. The patient also has gout. The patient has tried and failed Motrin, ibuprofen, Aleve, naproxen and Enbrel. Patient has also tried physical therapy (PT) and does stretching exercises. Per chart review patient is human leukocyte antigen B27 and inflammatory markers are normal, new findings of (sacroiliac)si joint (jt) ankylosis/sacroiliitis. The health plan's determination of medical necessity is overturned in whole. The patient has tried and failed conservative treatment with Motrin, ibuprofen, Aleve, naproxen and PT. The patient has even tried Enbrel. The provider believes there may be an inflammatory component to the back pain, which is why the provider tried Enbrel and is now requesting Cosentyx. Per chart review, the patient has sacroiliitis in which case a trial of Cosentyx is a reasonable next step in the treatment of this patient. According to the literature, in patients with AS who often have sacroiliitis, "secukinumab at a subcutaneous dose of 150 mg, with either subcutaneous or intravenous loading, provided significant reductions in the signs and symptoms of ankylosing spondylitis at week 16" (3).

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


Answer: The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary.

Context: The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF as not medically necessary. The health plan's determination is overturned. IVF is medically necessary for this patient. If services are not provided, the couple have a 25% chance of having a child with a fatal childhood disease. With the testing the chances of having a child with Tay-Sachs are less than 1%. IVF with PGT-M is in accordance with accepted standards of medical practice for this patient's circumstances.

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


Answer: This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup.

Answer: The patient had worsening symptoms despite

Answer: therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving

Answer: intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis.

Context: This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup. The health plan's determination of medical necessity is overturned.  The patient had worsening symptoms despite appropriate therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving appropriate and intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis.

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


Answer:
Diagnosis: Painful breast implants
Issue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast

Answer: The patient has periprosthetic capsular contracture, which is a known complication of breast implants.

Answer: The original procedure was for cosmetic purposes.

Context:
Diagnosis: Painful breast implants
Issue under review: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk, 19371 - Periprosthetic capsulectomy, breast

Determination:
The surgery is not medically necessary.

The patient has periprosthetic capsular contracture, which is a known complication of breast implants.  A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery.  The original procedure was for cosmetic purposes.  Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated.
The standard of care indicates that when implants are placed for reconstructive purposes, then treatment of these complications should be a covered service. However, in this case, the initial procedure of breast augmentation was a strictly a cosmetic procedure.  Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.   The ASPS position paper goes on to say that insurance carriers, "respond thoughtfully and with compassion on an individual basis," for several other conditions, including, "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)."
Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger.  The surgeon's note indicate that her breasts are soft and, based on this description and the photos, she does not have Baker IV capsular contracture.  Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.

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


Answer:
Diagnosis: Substance abuse disorder
Treatment: Inpatient detox

Answer: The patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco.

Answer: The patient displayed

Answer: a history of PTSD and depressive disorder and

Answer: ongoing substance use disorder with multiple substances of abuse.

Answer: the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes.

Context:
Diagnosis: Substance abuse disorder
Treatment: Inpatient detox

Summary:
The patient is an adult male who presented with a request for detoxification services. The patient reported that he was using alcohol, cannabis, and opioids (heroin), as well as a past history of sedative-hypnotic-anxiolytic use (benzodiazepine) and tobacco.

The proposed inpatient stay and detoxification treatment and other medical services could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of PTSD and depressive disorder and despite ongoing substance use disorder with multiple substances of abuse. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or other emotional disturbances that would have warranted an inpatient level admission and detoxification treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment and rehabilitation substance use treatment recently with discharge from another facility five days prior to admission. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with an extensive past history of multiple treatment episodes. Thus, an inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

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


Answer:
Diagnosis: Cholecystitis
Issue under review: Inpatient admission

Answer: In this case, the patient was young, healthy, with no comorbid conditions.

Answer: she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period.

Context:
Diagnosis: Cholecystitis
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The timing of cholecystectomy in patients presenting with acute cholecystitis has been under intense investigation, with "early" cholecystectomy variably defined in the literature as gallbladder surgery performed within three, seven, or 10 days of symptom onset, and "delayed" cholecystectomy as that performed seven or 45 days, or six weeks, after initial diagnosis. Evidence from large database reviews and randomized trials generally associates cholecystectomy performed early during the initial hospitalization with better outcomes.

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

Most otherwise healthy, reliable patients with good home support can leave the hospital within six hours after surgery. Cochrane reviews have found no significant differences for important clinical outcomes for patients discharged the same day versus admitted overnight following laparoscopic cholecystectomy. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, which included 15,248 patients older than 65 years of age who underwent elective laparoscopic cholecystectomy, identified congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis as significant independent predictors of inpatient admission and mortality.

The patient should have no activity restriction unless the umbilical incision was particularly large. Then, limited heavy lifting for a few weeks is advisable. Most patients are able to return to work within one week. Patients follow up in clinic two to four weeks after their operation.

Most patients have some abdominal pain that resolves within two to three days after surgery and can be managed with analgesics. Occasionally, patients have referred shoulder and neck pain from the CO2 insufflation causing diaphragmatic irritation.

In this case, the patient was young, healthy, with no comorbid conditions. In addition, she was not septic, had a normal white count and had a routine surgery without untoward events. She recovered as expected, and she exhibited no signs or symptoms of any complications in the immediate postoperative period.

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


Answer: The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.

Answer: the patient had an extensive treatment history with relapses

Answer: and presented with moderately severe withdrawal symptoms.

Context:
The patient is an adult who presented for inpatient detoxification treatment to address severe substance use disorder with opioid and stimulant class substances of abuse. The patient has a longstanding history of heroin use with more recent use of crack cocaine. He reported a past history of severe withdrawal symptoms when attempting to curtail use, and undergone multiple detoxification and rehabilitation treatments with relapses.

The health plan's determination is overturned. The treatment of this patient's substance use disorder with detoxification and withdrawal management did require the continued structure of an inpatient level setting and 24-hour monitoring in view of the patient's clinical presentation and course of treatment. Additionally, the patient had an extensive treatment history with relapses that supported the necessity for an inpatient level of care, and presented with moderately severe withdrawal symptoms. Withdrawal symptoms were appropriately managed with tapering dosages of methadone requiring monitoring and supportive measures including the availability of nicotine replacement therapy and comfort medications.

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


Answer: This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission.

Context: This is a patient who presented with a subjective fever, diarrhea for three days, and vomiting for two days. Four days prior to admission he had a cough and nasal congestion which cleared up with Saline nose spray and suction. He had 4-5 episodes of diarrhea each day for the last three days prior to admission. His mother noticed some bright red streaking in his diapers with almost every diarrheal stool. She also noted some hard stool chunks mixed with loose stool. She also noted that he seemed to cry in pain with passage of stool. He also had 5 episodes of non-bilious non-bloody emesis over the past two days prior to admission. The health plan's determination is upheld. His clinical findings, described in the chart, along with his laboratory findings support a mild degree of dehydration. There was no mention of a PO trial in the emergency room after he received an IV fluid bolus as oral rehydration therapy is the recommended first line for mild to moderate dehydration. He did not meet currently accepted criteria for admission to the hospital for dehydration.

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


Answer:
Diagnosis: Foot pain
Issue under review: Custom shoe orthotics

Answer: The patient has been using custom orthotics for several years and they have worn out, and the treatment has

Answer: been shown to be effective for the patient.

Context:
Diagnosis: Foot pain
Issue under review: Custom shoe orthotics

Determination:
The Custom shoe orthotics are medically necessary.

The treatment delivered is in keeping with reasonable acceptable standard of medical care for this condition.  Typically for plantar fasciitis, conservative care involves using custom orthotics.  The patient has been using custom orthotics for several years and they have worn out, and the treatment has already been shown to be effective for the patient.

Plantar fasciitis is typically treated with orthotics conservatively prior to more invasive treatment, such as corticosteroid injection and surgery.

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


Answer: This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care.

Context:
This is a patient who presented to the emergency department with persistent fevers and rash. He was well until approximately 5 days prior to admission when his mother noticed a red rash starting on his legs. The rash progressed to involve his back and stomach as well as his hands and feet. He also developed fever with a maximum temperature of 103.6 degrees Fahrenheit (F). He had been receiving ibuprofen at home with little relief, and he continued to have fevers. He was tolerating some oral intake, but had intermittent episodes of decreased activity. He was seen at his primary care provider's office where there was a concern for Kawasaki disease, and he was referred to the emergency department for further care.
The health plan's determination is overturned. The patient required prompt initiation of IVIG therapy along with high-dose aspirin in an inpatient setting to treat his symptoms and prevent the potentially serious complications of Kawasaki disease. He also had a blood culture sent that was pending. He required consultation from both infectious disease and cardiology, along with cardiorespiratory monitoring with further treatment as needed. Prompt treatment with intravenous immune globulin (IVIG) reduces the prevalence of coronary artery aneurysms fivefold in patients with Kawasaki Disease. Despite its advantages, IVIG is a potentially toxic intervention, and requires careful monitoring.

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


Answer: This a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.

Answer: Diagnosis:  Paranoid Delusions and Worsening Mania

Answer: Treatment: Inpatient Hospitalization

Answer: The insurer denied the Inpatient Hospitalization.

Answer: In this case, this patient had initially presented with manic and psychotic symptoms

Answer: Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured.

Context:
Diagnosis:  Paranoid Delusions and Worsening Mania

Treatment: Inpatient Hospitalization

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

This a female patient admitted to this inpatient mental health treatment in this hospital on in early 2019 due to psychotic and manic symptoms, including paranoid and grandiose delusional thinking, disorganized thinking, racing thoughts, flight of ideas, poor reality testing, agitation, and feelings of hopelessness and helplessness. It was reported that she took Zyprexa and Klonopin. Health care provider stated that she was free of suicidal ideation or psychosis and was able to care for self. They stated that she no longer required 24-hour hospital treatment then, and they recommended a less restrictive level of care. She improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. They also report that patients with aggression, homicidal or suicidal intent, plan, or behavior, manic episodes, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization. In this case, this patient had initially presented with manic and psychotic symptoms, but during hospitalization there were no further reports of manic episodes or psychotic symptoms. Further documentation reports that the patient was stable over the past week, and she did not have a labile mood, aggression, suicidal or homicidal ideation, or hallucinations. It was noted that her speech was linear and not pressured. There were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, homicidal ideation, plan, or intent, or severe agitation, acute medical instability or severe withdrawal requiring hospital treatment. The patient had no further severe psychiatric symptoms reported. Additionally, there were no reports of specific identifiable or quantifiable treatment objectives that could only be achieved in a 24-hour acute inpatient hospital setting or achieved in a less restrictive level of care.

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

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


Answer: This is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.

Answer: Diagnosis: Major Depressive Disorders

Answer: Treatment: Continued Inpatient Hospital Admission

Answer: The insurer denied the Continued Inpatient Hospital Admission.

Answer: She reportedly had suicidal ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment.

Answer: She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs.

Context:
Diagnosis: Major Depressive Disorders

Treatment: Continued Inpatient Hospital Admission

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

This is a middle age female who was admitted to an inpatient psychiatric hospital due to depressive symptoms that include depressed mood, suicidal ideation of not wanting to live but had no plan or intent. She also expressed feelings of worthlessness and isolation.  She had past history of Major Depression Disorder, seizures, cerebral palsy, and overactive bladder. She reports no previous psychiatric hospitalizations or treatments. The patient was treated with Lexapro, Abilify, Trazodone, Haldol, and Ativan. She was isolative but did participate in art group. While hospitalized, she remained depressed and suicidal. She was discharged after a period of stability.

Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization. She reportedly had suicidal ideation with depressed mood and feelings of worthlessness and was approved for hospital treatment. There were no reports of suicidal plan, intent, or behavior, self-injurious behavior, inability to adequately care for basic needs, psychotic or manic symptoms, aggressive, severely agitated, or threatening behavior, acute medical issues, or substance use issues as she denied substance use. She had no past suicide attempts, and no past psychiatric hospitalizations. She reportedly was living in a shelter but the chart notes that there was not specific evidence that she was an imminent danger to self or others or unable to adequately care for her basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting.

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

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


Answer: The patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this.

Answer: The patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.

Answer: The subject under review is the medical necessity of treatment with braces for this patient.

Context:
Overbite/Underbite
Dental/Orthodontic Procedure

The patient is a old female with a Class I, crowded occlusion and a deep bite causing soft tissue damage on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion which was denied based on lack of medical necessity.
The subject under review is the medical necessity of treatment with braces for this patient.

The health plan's determination is overturned.

The requested treatment of braces is medically necessary for this patient.
The patient's orthodontist has documented that the patient is damaging the soft tissue of her palate due to her deep overbite, and her cephalometric radiograph confirms this. Palatal tissue damage is a known side effect of deep bite malocclusions.(1)

A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of her palate. Studies show deep anterior overbite is associated with periodontal attachment loss.(1) If left untreated this will compromise the bony attachment of the maxillary anterior teeth. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive to correct than the orthodontic problem she currently has.

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


Answer: The patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.

Answer: In question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29.

Context:
Decay, Root Involvement
Dental /Orthodontic Procedure

The patient who presented to the dental office of the  provider for the evaluation and treatment of teeth #5 and 29. Provided for review are a narrative from the dental provider explaining radiographic opening under current restoration for #5 and 29 along with recurrent decay, full mouth radiographic images from 05/02/18, bite-wing images from 07/09/19, panoramic radiographs from 05/02/18, and American Dental Association (ADA) Dental Claim Forms.
In question is the medical necessity of the planned treatment of (2751) porcelain crown and (2954) prefabricated post and core for teeth #5 and 29.
The health plans determination of medical necessity is upheld in whole .
Based on the provided documentation there is no evidence of decay radiographically nor clinically to support the need for the requested treatment of (2751) porcelain crown and (2954) pre-fabricated post and core for teeth #5 and 29.The current documentation does not support the presence of decay at the margins of #5 and 29 neither clinically nor radiographically, hence removing any rationale for the replacement of the current crowns on those teeth. Because there is not a medical necessity need for the porcelain crowns, there is also not the need for post core and buildup for either teeth. Without evidence of decay radiographically or clinically to support the need for the planned treatment of porcelain crown and prefabricated post and core for teeth #5 and #29,  medical necessity cannot be established.

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


Answer:
Diagnosis: Chest pain
Treatment: Inpatient admission

Answer: The patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.

Answer: This patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated.

Context:
Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a woman who presented to the hospital complaining of chest pain for over one year. On examination vital signs were stable and chest pain was reproducible when palpating the sternum.  No other abnormal findings were noted. Past medical history was significant for diabetes mellitus.  Electrocardiogram revealed no evidence of ischemic changes and serial cardiac enzymes were within normal limits.  Computed tomography (CT) of the chest to rule out pulmonary embolism was normal.  The patient was ultimately discharged with outpatient follow up.

This patient presented with atypical chest pain that was present for one year's time.  Chest pain was reproducible when the sternum was palpated. Based on history and physical examination her pretest probability of coronary artery disease is low. (Reference 1)  Utilizing the HEART score she was considered low risk (three points). (Reference 2)  Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3)

Risk assessment of patients presenting with chest pain and no significant ST changes on electrocardiogram (ECG) was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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


Answer:
Diagnosis:  Psoriasis Vulgaris
Treatment:  Consentyx

Answer: The patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.

Answer: The patient has already tried methotrexate.

Context:
Diagnosis:  Psoriasis Vulgaris
Treatment:  Consentyx

The proposed Cosentyx is medically necessary.

The patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.

Cosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis.  Currently, the selection of the first biologic and the choice of sequential biologics in the event of efficacy/tolerability concerns is made using a limited evidence base.  It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded.

The patient has already tried methotrexate.  Cyclosporine is not used for plaque psoriasis.

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


Answer: The patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.

Answer:
Diagnosis:  Dental Disorder.
Treatment:  Dental Implant Tooth #19.

Answer: The insurer denied the Dental Implant for Tooth #19.

Context:
Diagnosis:  Dental Disorder.
Treatment:  Dental Implant Tooth #19.

The insurer denied the Dental Implant for Tooth #19.  The determination is overturned.

The patient presented to the oral surgeon for dental implant placement at the site of missing tooth #19.  The implant was performed.  At issue is the medical necessity of the dental implant for tooth # 19.

It is reasonable to restore a patient's dentition to first molar occlusion, which this procedure did.  It is considered a fairly predicable surgery with a high success rates with a variety of implant systems and applications (89 to 98 percent).  Replacement of missing teeth with dental implants is common practice in dentistry.  Loss of teeth without replacement may have several adverse outcomes, including among others masticatory dysfunction, speech and articulation errors, and pain secondary to chronic mucosal irritation and ulceration.  Since there is no tooth posterior to tooth #19, there is only a removable option, which is a partial denture, which is considered less ideal because it is removable versus fixed (which an implant is) and also because it is more suited to replacement of multiple teeth versus just one.  Therefore, the dental implant for tooth number 19 is medically necessary.

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


Answer: The patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.

Answer: Diagnosis: Atrial Fibrillation

Answer: Treatment: Inpatient Hospital Stay

Answer: The insurer denied the Inpatient Hospital Stay.

Answer: This patient was hemodynamically stable

Answer: This patient's serum troponin level was mildly elevated.

Answer: In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted.

Context:
Diagnosis: Atrial Fibrillation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of hypertrophic cardiomyopathy and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He also reported having had a few days of chills, cough and myalgias. He denied chest pain or dyspnea. His blood pressure was 115/86 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. He was afebrile. His physical exam was unremarkable. Testing was positive for Influenza A. His serum troponin level was mildly elevated. He was treated with Tamiflu and intravenous digoxin and admitted to the hospital due to concern for acute coronary syndrome (ACS) based on the elevated troponin level. He was seen by a cardiologist who opined that there was no evidence of acute coronary syndrome (ACS). The patient was discharged. The medical necessity of an inpatient admission is at issue.

The inpatient stay was not medically necessary.
This patient was hemodynamically stable, there was no evidence of acute ischemia, he was not in decompensated heart failure, and was not at high risk for thromboembolism. For patients presenting with acute atrial fibrillation (AF), the safety a lower level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."
This patient's serum troponin level was mildly elevated. This is a common finding in patients presenting with supraventricular tachyarrhythmias, including atrial fibrillation, and is not necessarily indicative of coronary artery disease or acute coronary syndrome. In this case, per the cardiologist, there was no evidence of ACS and no treatment for ACS was instituted. Thus, the troponin elevation in this case did not warrant an inpatient level of care.

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


Answer: This is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs).

Answer: documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping.

Answer: Diagnosis: Alzheimer's dementia

Answer: Treatment: Consumer directed personal assistance services 50 hours per week

Context:
Diagnosis: Alzheimer's dementia
Treatment: Consumer directed personal assistance services 50 hours per week

Summary:
This is a female with a history of Alzheimer's dementia. Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs). The currently approved plan of 35 CDPAS hours/week is not sufficient to meet the patient's needs. Specifically, documentation from the patient's physician indicates that the patient's functionality and clinical status have progressively declined and she currently requires assistance with all ADLs including eating, cooking, bathing, toileting and laundry/housekeeping. For these reasons, the CDPAS at 50 hours per week is deemed medically necessary.

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


Answer: The patient has Crohn's, and she has failed Remicade and Humira.

Answer: Diagnosis: Chron's Disease.

Answer: Treatment: Stelara (ustekinumab).

Answer: The insurer denied the Stelara (ustekinumab).

Answer: The patient is a female with ileocolonic Crohn's. She has failed treatment with

Answer: sulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara.

Context:
Diagnosis: Chron's Disease.
Treatment: Stelara (ustekinumab).
The insurer denied the Stelara (ustekinumab).
The denial is upheld.

The patient is a female with ileocolonic Crohn's. She has failed treatment with
sulfasalazine, 6-MP (mercaptopurine), Methotrexate, Remicade and Humira. Her MD is requesting treatment with Stelara.

No, the treatment with Stelara (ustekinumab) is not medically necessary.

The patient has Crohn's, and she has failed Remicade and Humira. Per plan guideline, in order for criteria for Stelara to be met, the patient must have tried and failed Entyvio. As Entyvio is safe and effective treatment in patients with Crohn's who have failed an anti-TNF (tumor necrosis factor), and as there is no consensus in the literature supporting that Stelara is more effective than Entyvio for the treatment of Crohn's, the proposed Stelara is not medically necessary over the plan-preferred Entyvio, and the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying it.

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


Answer: This is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.

Answer: Diagnosis:  Appendicitis.

Answer: Treatment:  Inpatient hospital admission.

Answer: The insurer denied the inpatient hospital admission.

Answer: This patient had fever up to 102.

Answer: He was started on clear diet in the morning, and his diet was advanced that evening.

Context:
Diagnosis:  Appendicitis.
Treatment:  Inpatient hospital admission.

The insurer denied the inpatient hospital admission.  The denial was overturned.

This is a patient who presented to the Emergency Department with complaints of abdominal pain.  The patient reported that he had constant and moderate abdominal pain with loose bowel movements in the morning.  The physical examination revealed right lower quadrant abdominal tenderness and suprapubic region tenderness to palpation with no rebound or guarding.  The white blood cell count was 15.5.  CT scan of the abdomen and pelvis revealed acute appendicitis.  The patient decided to undergo non-surgical management and was treated with intravenous (IV) fluids, IV antibiotics, and pain medications.  The patient was discharged with follow-up for appendectomy planning with the general surgeon.

The length of hospital stay for this patient is consistent with what is seen in most studies on patients with uncomplicated appendicitis treated non-operatively.  Intravenous (IV) antibiotics is generally recommended for 3 days, typically on an inpatient basis, then followed by 7 days of oral antibiotics on an outpatient basis if patient responds to IV antibiotics.  Discharge criteria for patients with uncomplicated appendicitis treated non-operatively is antibiotics, control of pain with oral analgesics, and resolution of fever.  This patient had fever up to 102.  Another criteria that has been looked at for discharge is that the patient tolerates their diet (3).   He was started on clear diet in the morning, and his diet was advanced that evening.  Discharge the following day is reasonable, as it allowed for 24 hours of being afebrile, insured that he tolerated diet, and also that his WBC was improving.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.

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


Answer: Diagnosis: Obstruction of vision

Answer: Treatment: Blepharoplasty

Answer: The insurer denied the Blepharoplasty.

Answer: The patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria.

Answer: According to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.

Answer: In this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU.

Context:
Diagnosis: Obstruction of vision
Treatment: Blepharoplasty
The insurer denied the Blepharoplasty.
The denial is overturned.

The patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria.

According to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.

Yes, the blepharoplasty performed 06/10/2019 was medically necessary.

No, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  However, it should be noted that the health plan reportedly did not have the external photos that were provided for this current review.

According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Photos should correlate with visual field testing.

A task force from the American Academy of Ophthalmology reviewed the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.  Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:

1) Marginal reflex distance one (MRD1) of two mm measured in primary gaze (MET)
2) Superior visual field loss of 12 degrees or 24% (MET)
3) Down-gaze ptosis impairing reading documented by MRD1 of two mm measured in down gaze.

In this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU. Photos correlate with the required superior visual field loss.  Therefore, medical necessity of bilateral upper eyelid blepharoplasty is established per standard of care.

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


Answer: The patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.

Answer: This patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care.

Answer: The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization)

Answer: Diagnosis: Cardiac / Circulatory Problems.

Answer: Treatment: Inpatient Hospital.

Answer: The insurer denied: Inpatient stay.

Context:
Diagnosis: Cardiac / Circulatory Problems.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial was overturned in whole.

The patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.

The health plan's determination is overturned in whole.

An inpatient stay was medically necessary for this patient.
This patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care. Urgent coronary angiography was medically appropriate with the goal of treating ischemic symptoms and reducing the risk of myocardial infarction. The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization) favoring benefit with urgent coronary angiography (1). Furthermore, according to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guideline for the management of patients with non-ST-elevation acute coronary syndromes, the standard of care for patients with unstable angina, as in this case, is admission for inpatient management to reduce ischemic symptoms and prevent myocardial infarction and death (2). For these reasons, inpatient level of care was medically appropriate and necessary in the best interest of this patient's safety.

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


Answer: Diagnosis: Autism spectrum disorder

Answer: Treatment: 97153 - ABA therapy, five hours/week

Answer: This is an adult male diagnosed with autism spectrum disorder (ASD) at age three years

Context:
Diagnosis: Autism spectrum disorder
Treatment: 97153 - ABA therapy, five hours/week
The proposed treatment, ABA therapy, is not medically necessary.

This is an adult male diagnosed with autism spectrum disorder (ASD) at age three years; the source of that diagnosis is not documented.

Despite the lack of evidence from randomized controlled trials, there is growing evidence from observational studies and systematic reviews and a consensus in the professional community that children with autism spectrum disorder (ASD) should participate in therapeutic programs as early as possible.  Almost all evidence concerning efficacy of psychosocial interventions in ASD is based on studies of children 18 months to seven years of age.  A systematic review concluded there was insufficient evidence (ie, not studied, poor-quality studies) to support the use of ABA therapy in the treatment of adolescents (such as this patient) or adults with ASD.  A systematic review of the effectiveness of behavioral, educational, life skills, or vocational interventions in people with ASD found variable effects on activities of daily living (ADLs), and have indicated that generalizability of positive findings in this area is limited due to insufficient evidence (ie, lack of study of some domains, poor quality studies).  Thus, the use of ABA for children age 12 years and older (such as this patient) must focus on the core features of ASD rather than on ADLs (which is not the case for this patient) [Smith 2015, Murza 2016, Reichow 2018, Volkmar 2018].
...
DURATION OF THERAPY.
The patient should receive ABA therapy for a minimum of 12 months, until:
1) Treatment goals are reached
2) Patient plateaus and fails to progress (i.e., maintenance therapy)
3) Four years of therapy

The diagnosis of ASD is not substantiated for this patient because clinical records fail to document a diagnostic evaluation for ASD by a qualified diagnostician (e.g., clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral pediatrician, board-certified neurodevelopmental pediatrician) administering an appropriate module of the ADOS-2 accompanied by review of the DSM-5tm diagnostic criteria along with standardized testing of intelligence and language.  Even if the diagnosis of ASD were substantiated, continued ABA therapy for more than four years is not medically necessary, appropriate, or standard of care.  Finally, the patient has shown poor RTI despite many years of ABA therapy, further supporting that the requested services are not medically necessary.

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


Answer: This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs.

Answer: The patient has a diagnosis of hypertensive urgency or emergency

Context:
Cardiac/Circulatory Problems
Inpatient hospital

This is a case of a man with a history of hypertension diabetes and hyperlipidemia, presenting to the emergency room with complaints of left shoulder and arm pain, with radiation into the left hand. Symptoms have been present for at least a week, with associated intermittent headaches and blurred vision. The patient denied chest pain or shortness of breath. There was no associated nausea or vomiting. Vital signs on arrival included a temperature of 97.9 Fahrenheit, respirations of 26, and blood pressure of 204/127. The heart rate at this time is documented at 84 beats per minute (bpm). On exam, the patient is described as well-appearing well-nourished awake, and alert. The cardiac exam showed a regular rate and rhythm with normal heart sounds and no murmurs. The pulmonary exam was fairly unremarkable, and so was the rest of the exam.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This presentation of hypertensive urgency can be managed under at a lower level of care. The presentation does not satisfy clinical indications for admission to inpatient care. The patient has a diagnosis of hypertensive urgency or emergency, without evidence of target organ damage. There is no evidence of hypertensive encephalopathy or cerebral infarction. There is no evidence that the patient suffered from myocardial ischemia or infarct. There is no evidence of heart failure or aortic dissection. There is no evidence of seizure activity associated with hypertensive urgency. Within 24 hours, the addition of antihypertensive medications produced adequate control of blood pressures. This type of presentation is typically managed at a lower level of care for chest pain rule out protocol.

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


Answer: Diagnosis: Rectal bleeding

Answer: Issue Under Review: Inpatient admission

Answer: The patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia.

Answer: On presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up.

Answer: The patient presented with anemia and received two units of blood. The patient evidenced

Answer: generalized weakness from the anemia.

Context:
Diagnosis: Rectal bleeding
Issue Under Review: Inpatient admission

Determination: The inpatient admission was not medically necessary.

The patient is a male. He was admitted via the emergency department to the hospital.  The patient noted rectal bleeding and generalized weakness the morning of presentation. The impression was hemorrhoidal bleeding as the most likely cause. The patient evidenced anemia.

On presentation, the patient had a hemoglobin of 6. He received two units of blood and evidenced no bleeding during the hospitalization. The patient was discharged with a plan for close follow-up.

The patient presented with anemia and received two units of blood. The patient evidenced only generalized weakness from the anemia. There was no reported hypoxia, active bleeding, coagulopathy, or planned surgery. The care as rendered could have been delivered at a lower level of care in its entirety.

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


Answer: This is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.

Answer: Diagnosis: Fecal Impaction

Answer: Treatment: Inpatient admission

Answer: The insurer denied the inpatient admission.

Answer: The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction.

Context:
Diagnosis: Fecal Impaction

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a medical history of hemorrhoidectomy and an abdominoplasty. The patient presented to the Emergency Department (ED) with complaints that she had not had a bowel movement since the hemorrhoidectomy. The patient had been diligently taking her opioids and eating regularly.  The patient denied abdominal pain, but did complain of nausea. She reported that sometimes she passed gas but had not passed gas on the date of presentation. Her presenting vital signs were: blood pressure 106/71 and temperature 36.7 C.  A physical examination was performed that revealed her abdomen was soft and non-tender. An abdominal x-ray was done that revealed no evidence of free air or obstruction. The patient's surgeon recommended she come to the ED for an enema under sedation. The patient underwent an examination under anesthesia, minimal fecal disimpaction, and irrigation of the rectum with saline and Betadine. The patient was discharged in stable condition.

Based on the review of the medical record and literature, the inpatient admission was not medically necessary. The patient had post-operative constipation compounded by opiate use. The patient was hemodynamically stable and her labs were unremarkable. The patient's abdominal imaging did not reveal ileus or obstruction. While fecal disimpaction was appropriate, inpatient admission was not medically necessary. The patient could have received her care in the Emergency Room (ER) or at Observation level of care.

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

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


Answer: The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.

Answer:
Diagnosis: Autoimmune encephalitis with refractory seizures
 Treatment: Octagam

Answer: The insurer denied coverage for Octagam.

Answer: This patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.

Answer: Additional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall.

Context:
Diagnosis: Autoimmune encephalitis with refractory seizures
 Treatment: Octagam

The insurer denied coverage for Octagam. The denial is reversed.

This patient is a male who has been previously diagnosed with Crohn's disease.  A letter of medical necessity indicates the patient was also being seen by Neurology for a complex neurological condition.  The patient was noted to have autoimmune encephalitis with secondary intractable epilepsy.  The patient had an explosive onset 6 months prior with multiple and refractory focal seizures with secondary generalization captured during a prolonged hospital stay.  The patient has undergone extensive evaluation to include CSF examination which returned a positive result for high levels of myelin basic protein.  The patient did respond well to an initial course of Solu-Medrol and an attempt to taper then led to worsening seizure frequency.  The patient was utilizing 2 AEDs at very high doses in combination with oral prednisone.  The patient was recommended to continue chronic immunosuppression.

Additional submitted documentation does include a chart note when the patient was seen for a follow-up.  The documentation did detail the patient was recently admitted for an episode worsening seizures.  The patient responded well to Solu-Medrol in addition to valproic acid (VPA).  The patient did attempt to taper off steroids as noted above however this worsened the seizures.  The documentation detailed the patient was feeling okay since the hospital visit.  The physician indicated the patient presented with a new onset seizure-like event following a fall.  By description and video review, events are atypical for seizures; however recent evaluation confirmed the epileptic nature.  The documentation indicated the recent emergent admission in response to Solu-Medrol, as well as worsening seizures with steroid discontinuation, supports the autoimmune etiology of epilepsy.  It was recommended the patient continue multiple medications and begin IVIG.

IVIG is commonly used for cases of autoimmune encephalitis with refractory seizures and is in the standard of care. A variety of clinical studies, some randomized, blinded studies have shown efficacy with IVIG.  Therefore, the use of Octagam is medically necessary in this case for this patient with treatment failure with steroids and multiple anticonvulsant medications.  The decision is overturned and Octagam should be approved in this case.

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

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

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


Answer: The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids.

Answer: The patient is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate) due to her gender and childbearing age.

Answer: Diagnosis: Atopic dermatitis

Answer:
Treatment: Dupixent Syn 300
The insurer denied the Dupixent Syn 300.

Answer: The patient is a female with a history of moderate to severe atopic dermatitis (AD) since adolescence. She has failed topical therapy. She has severe fissuring of the hands and ears. Her EASI (Eczema Area and Severity Index) score is 18.7, and IGA (Investigator's Global Assessment) is four. The medical chart note documents that she was not treated for 1.5 years and is currently looking for a new job, so cannot do phototherapy. She drinks alcohol and has a family history of hypertension. At that visit, she was prescribed tacrolimus, Eucrisa, halobetasol and Dupixent.

Answer: The patient has severe atopic dermatitis affecting multiple areas of the body, including the hands and ears. She is a candidate for systemic therapy, as the BSA (body surface area) is too large for reasonable control with topical medications.

Context:
Diagnosis: Atopic dermatitis
Treatment: Dupixent Syn 300
The insurer denied the Dupixent Syn 300.
The denial is overturned.

Yes, the treatment with Dupixent Syn 300 is medically necessary.

The patient is a female with a history of moderate to severe atopic dermatitis (AD) since adolescence. She has failed topical therapy. She has severe fissuring of the hands and ears. Her EASI (Eczema Area and Severity Index) score is 18.7, and IGA (Investigator's Global Assessment) is four. The medical chart note documents that she was not treated for 1.5 years and is currently looking for a new job, so cannot do phototherapy. She drinks alcohol and has a family history of hypertension. At that visit, she was prescribed tacrolimus, Eucrisa, halobetasol and Dupixent.

The patient has severe atopic dermatitis affecting multiple areas of the body, including the hands and ears. She is a candidate for systemic therapy, as the BSA (body surface area) is too large for reasonable control with topical medications. Topical calcineurin inhibitors (tacrolimus) and topical steroids are not appropriate therapy for severe, widespread atopic dermatitis, affecting sensitive areas, which should be treated with systemic therapy.

Dupilumab is a monoclonal antibody that inhibits IL-4 and IL-13 signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase 2 clinical trials. In March 2017, it was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 mg and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of 0 or 1 (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (8-10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD. The patient has failed topical steroids, calcineurin inhibitors, and systemic steroids. Additionally, topical calcineurin inhibitors are not indicated for severe disease.

Phototherapy is not appropriate for sensitive areas and impossible to obtain during the COVID-19 pandemic. Cyclosporine, azathioprine, methotrexate, mycophenolate mofetil  are not FDA-approved for use in atopic dermatitis (Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is. The patient is not a candidate for conventional systemic therapy (methotrexate, azathioprine, mycophenolate) due to her gender and childbearing age. Systemic steroids and cyclosporine are not a reasonable long-term treatment for moderate to severe atopic dermatitis due to their severe side effect profile.

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


Answer: Diagnosis: Malocclusion

Answer: Treatment: Braces and monthly visits

Answer: The insurer is denied coverage for the braces (D8080) and monthly visits (D8670).

Answer: the patient exhibited a malocclusion.

Answer: this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care.

Context:
Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer is denied coverage for the braces (D8080) and monthly visits (D8670).

The denial is upheld.

The patient was a male child. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the HLD index attaining 11 total points to support orthodontic care.

It is evident that the patient exhibited a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 11 points to justify for this patient's orthodontic care.  This reviewer concurs with the index completed by this patient's orthodontist attaining a total of 11 points on the HLD index (1 points overjet, 1 points overbite, 5 points anterior crowding, 4 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Since this patient's HLD index total score was 11, which was below the threshold of 26 points to justify for orthodontic care, the braces and the monthly visits associated with braces are not medically necessary for this patient.

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

The carrier's denial of coverage for the braces (D8080) and monthly visits (D8670) should be upheld.  The medical necessity is not substantiated.

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


Answer: The patient who has been diagnosed with type 1 diabetes since the age of 10 years.  The patient has been treated with multiple daily insulin injections.

Answer: This patient has been diagnosed with type 1 diabetes, and control has been excellent; however, she has developed lipoatrophy associated with multiple daily insulin injections, so the patient is on inhaled insulin to minimize the number of injections that are medically necessary and reasonable, as the patient had developed lipohypertrophy from insulin injections, which ultimately led to lipoatrophy.

Answer: Diagnosis:  Endocrine/Metabolic - Diabetes.

Answer: Treatment:  Pharmacy Prescription drugs.

Answer: The insurer denied medication Afrezza.

Context:
Diagnosis:  Endocrine/Metabolic - Diabetes.
Treatment:  Pharmacy Prescription drugs.
The insurer denied medication Afrezza.  The denial is overturned.

The patient who has been diagnosed with type 1 diabetes since the age of 10 years.  The patient has been treated with multiple daily insulin injections.

The requested health service treatment of Afrezza is medically necessary for this patient.  Glycemic control is fundamental to the management of diabetes.  The Diabetes Control & Complications Trial (DCCT) study showed definitively that improved glycemic control is associated with significantly decreased rates of microvascular (retinopathy and nephropathy) and neuropathic complications.  As intensive diabetes management is associated with significantly decreased rates of microvascular and neuropathic complications, target HbA1C should be < 7% and achievement of HbA1C < 6.5%, if achieved safely without significant hypoglycemia, may be acceptable.

This patient has been diagnosed with type 1 diabetes, and control has been excellent; however, she has developed lipoatrophy associated with multiple daily insulin injections, so the patient is on inhaled insulin to minimize the number of injections that are medically necessary and reasonable, as the patient had developed lipohypertrophy from insulin injections, which ultimately led to lipoatrophy.

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


Answer: The patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).

Answer: The patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge.

Answer: Diagnosis: Alcohol withdrawal; history of polysubstance abuse

Answer: Treatment: Inpatient admission

Answer: The insurer denied the inpatient admission.

Answer: This patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile.

Answer: The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal.

Context:
Diagnosis: Alcohol withdrawal; history of polysubstance abuse
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history of polysubstance abuse. She was admitted to the medical floor from detox for alcohol withdrawal after wanting to sign out AMA (against medical advice).

The patient's VS (vital signs) were as follows: 97.9, 77, 18, 148/92, 96%. Her exam was unremarkable. She exhibited no signs of DTs (delirium tremens). She had no neurologic deficit. CBC (complete blood count) and BMP (basic metabolic panel) was unremarkable. EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Head CT showed NAD (no active disease). The plan was for management with Librium tapering dose. The patient had no capacity per Psych evaluation. The patient was placed on one-to-one for elopement risk per psych. The plan was for consult psych for reevaluation. The patient's alcohol withdrawal resolved. She was cleared for discharge.

This patient was admitted for management of alcohol withdrawal and discharged. The patient was hemodynamically stable and afebrile. She did not have tachycardia. She did not have persistent vomiting. She did not have gross tremor. Labs were unremarkable. The plan was for management with Librium taper. The patient was clinically stable and did not have findings of alcohol withdrawal. She did not have symptoms that required an acute inpatient level of care. The requested inpatient admission was not medically necessary.

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


Answer: the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the "cement" used as a filling material does not negatively affect long term tooth retention/health.

Answer: The existing restoration placed on this endodontically treated tooth appears to be failing.

Answer: Diagnosis: Dental issue

Answer: Treatment: Dental core buildup on tooth #30

Answer: The insurer denied coverage for D2950, (core buildup, including pins) on tooth #30

Answer: This is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30.

Context:
Diagnosis: Dental issue

Treatment: Dental core buildup on tooth #30

The insurer denied coverage for D2950, (core buildup, including pins) on tooth #30

The denial is overturned.

This is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30.

Upon review of the submitted documentation, the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the "cement" used as a filling material does not negatively affect long term tooth retention/health.

The existing restoration placed on this endodontically treated tooth appears to be failing. Given this clinical circumstance, core buildup and placement of full coverage crown is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such the service noted above, which is a covered service for this individual, is deemed medically necessary.

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

The carrier's denial of coverage for D2950 (build-up) on tooth #30 is overturned.  The medical necessity is substantiated.

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


Answer: Diagnosis: Cellulitis, Abscess

Answer: Treatment: Inpatient admission

Answer: The insurer denied the inpatient admission.

Answer: This is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).

Answer: the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse.

Context:
Diagnosis: Cellulitis, Abscess
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was overturned.

This is female patient with immunocompromised status and a past medical history significant for substance abuse and depression. The patient presented to the Emergency Department (ED) with complaints of right ankle swelling and erythema.  The patient's vital signs on presentation were: temperature 98.2 F, blood pressure 147/76, pulse 86, respiratory rate 20, and oxygen (O2) sat-99% on room air. The patient's laboratory results included the following: white blood cell (WBC)-11.4, hemoglobin-11.6, hematocrit-36.3, creatinine-0.91, glucose-167, ESR-69, CRP-1.1, and urine toxicology positive for cocaine and opiates. The patient was admitted to the hospital for cellulitis/abscess of the right ankle; she received intravenous (IV) antibiotics. Surgery was consulted and an incision and drainage (I&D) was performed. The patient's wound culture grew methicillin-resistant staphylococcus aureus (MRSA). The patient refused magnetic resonance imaging (MRI). The patient received wound care. The patient had an episode of hypotension prior to signing out against medical advice (AMA).

According to medical record, the patient presented with a right ankle abscess. The patient's laboratory results showed elevated white blood cell (WBC) count, anemia, and increased ESR. The patient's urine toxicology was positive for substance abuse. Based on these clinical findings in a high-risk patient with immunocompromised status, inpatient admission was medically necessary for administration of intravenous antibiotics and surgical intervention.

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 is overturned.

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


Answer: This patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved.

Answer: Diagnosis: Celiac disease and intestinal metaplasia

Answer: Treatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple)

Answer: The insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple).

Context:
Diagnosis: Celiac disease and intestinal metaplasia
Treatment: 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple)

The insurer denied coverage for 43239 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple). The denial is reversed.

This patient is a female diagnosed with both celiac disease and intestinal metaplasia in the gastric antrum on biopsies performed during endoscopy a few years ago. The patient had been on a strict gluten-free diet and her symptoms have improved.

According to UptoDate article on gastric intestinal metaplasia, endoscopic surveillance with gastric biopsies is advised for this patient. Literature evidence suggests that surveillance may lead to early detection of gastric cancer and improved survival. However, the optimal surveillance interval has not been fully determined. UpToDate article on "Management of celiac disease in adult" states that the consensus is that re-biopsy should be undertaken after commencing a gluten-free diet to confirm a satisfactory response to the diet.

This patient had two conditions which required careful follow up. Both intestinal metaplasia and celiac disease diagnoses increase this patient's risk for malignancy, and a close follow-up with endoscopic monitoring was medically necessary.

Thus, esophagogastroduodenoscopy (EGD) with biopsy was medically necessary to properly monitor and treat this patient's medical condition.

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

The carrier's denial of coverage for procedure Code 4323 (Esophagogastroduodenoscopy [EGD] transoral biopsy single/multiple) is reversed. The medical necessity is substantiated.

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


Answer: The patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.

Answer:
Diagnosis:  Blood Disorder.
Treatment:  Pharmacy/Prescription Drugs (Pradaxa).

Answer: The insurer denied the Pradaxa.

Answer: The patient has failed the formulary drugs Eliquis and Xarelto

Context:
Diagnosis:  Blood Disorder.
Treatment:  Pharmacy/Prescription Drugs (Pradaxa).

The insurer denied the Pradaxa.  The denial is upheld in whole.

The patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.

The health plan's determination is upheld.

The patient has failed the formulary drugs Eliquis and Xarelto, and, thus, they are not appropriate for this patient.  The formulary drug warfarin has similar clinical efficacy to the non-formulary Pradaxa and is not contraindicated in this clinical scenario.  A LexiDrugs interaction check states "...Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists.  This appears most likely with daily acetaminophen doses exceeding 1.3 or 2 grams per day (g/day) for multiple consecutive days....  Monitor for increased therapeutic effects of anticoagulants if acetaminophen is initiated/dose increased, or decreased effects, if acetaminophen is discontinued/dose decreased....  Use for more than 3 consecutive days may warrant additional international normalized ratio (INR) testing....".

Therefore, if this patient is intensively monitored, there is likely minimal risk to the use of warfarin with his current medical regimen.

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