Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for acute hospitalization until a definitive diagnosis is determined; subacute hospitalization thereafter for the duration of recovery; one-on-one sitter to monitor risk of aspiration with oral suctioning; physical therapy; occupational therapy; speech therapy; a gastroenterology consultation/second opinion; neurology consultation/second opinion; an otolaryngology consultation/second opinion; a neuro-oncology consultation/second opinion; and/or a cardiology consultation. Based on the available documentation, this patients vomiting could be multifactorial due to her chronic medical conditions. The cause for her intractable vomiting has not been determined. The patient has been treated for gastroparesis with placement of a J-tube, consistent with the recommendations from the American College of Gastroenterology (ACG). In addition, the patient underwent an upper-endoscopy a few months ago, which showed gastritis. Therefore, evaluation by gastroenterology is warranted while the patient is in the acute hospital setting for evaluation of gastritis or peptic ulcer disease. The patient has poor oral intake with a calorie deficient diet due to vomiting. Required nutritional intake should be addressed while the patient is in the acute hospital setting. Based on the patients complaints of chest pain, the patient should have a basic work-up by a cardiologist. A cardiologist can evaluate the origin of her chest pain and determine whether additional testing is indicated. Further, a consultation with neurology to evaluate the patients recurrent seizures. This evaluation is imperative to help determine the patients loss of consciousness. Thus, the requested gastroenterology consultation/second opinion, neurology consultation/second opinion, and a cardiology consultation are medically necessary. However, the records do not support the requested otolaryngology consultation/second opinion and neuro-oncology consultation/second opinion as medically necessary. In addition, the patient should be evaluated by a speech therapist, physical therapist, and occupational therapist while in the acute hospital setting. The patients physical activity and speech abilities improved while she was in the rehabilitation facility. Given these findings, the patient should receive acute hospitalization until her vomiting has resolved and her nutritional required intake is adequately addressed. Evaluations by physical therapy, occupational therapy and speech therapy should occur in the acute hospital setting. The patient should be evaluated for subacute care after resolution of these issues. The records do not support the medical necessity of a one-on-one sitter to monitor risk of aspiration with oral suctioning. In sum, acute hospitalization until vomiting has resolved and nutritional required intake are addressed; evaluations with physical therapy, occupational therapy, and speech therapy in the acute hospital setting; a gastroenterology consultation/second opinion, neurology consultation/second opinion, and a cardiology consultation in the acute hospital setting; are medically necessary for this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pulmonary disease with subspecialty certifications in internal medicine and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.