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Ischemic heart disease
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Recommended: Ischemic heart disease
The records have been reviewed. The member is an adult male with a birth date of 02/09/1959. He has a diagnosis of ischemic cardiomyopathy. His treating provider, Maria Costanzo, MD, recommended the Zoll LifeVest (wearable cardioverter defibrillator) for the following dates of service 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 (totaling 4 units). The carrier has denied coverage for the Zoll LifeVest as experimental and/or investigational and not medically necessary. A letter from the carrier to the member, dated 07/05/2016, which states in part: “As you can see from the wearable cardioverter-defibrillator coverage policy cited above, a LifeVest is only allowed when it has been determined that an ICD is needed, the criteria …show more content…
The use of a WCD is not always appropriate. Given the clinical features of this case and aforementioned review of information, the benefit of a WCD would be insufficient to warrant coverage. Therefore, coverage of a WCD not recommended for this member. Therefore, the carrier’s decision to deny coverage for the Zoll LifeVest (K0606-wearable cardioverter defibrillator) for the dates of 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 as experimental and/or investigational was appropriate. The Zoll LifeVest (K0606-wearable cardioverter defibrillator) for the dates of 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 was not medically necessary for the treatment of this member’s condition. The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or treatment. The adverse risks of the recommended or requested health care service or treatment are not substantially increased over those of available standard health care services or
Transcatheter aortic valve replacement or TAVR is the latest technology used principally for the treatment of aortic stenosis, a condition in which one of the major valves of the heart, the aortic valve, becomes tight and stiff, usually as a result of aging (3). Since many patients who need aortic valve replacement for aortic stenosis are too sick to undergo major valve replacement surgery, they are unable to get the treatment they need. With the transcatheter aortic valve, this issue is bypassed because this valve can be implanted in the heart by accessing the patient’s heart through an artery in the groin. The valve can be inserted through a wire that can be pushed to the heart and the old valve is simply pushed to the side when the new valve is implanted. This technology has been in use in the US with Edwards’ Sapiens valve since 2011 and has saved the lives of many patients with aortic stenosis (4). Medtronic’s CoreValve uses similar technology and has won patent fights in Europe and has been in use internationally. However, within U.S., Medtronic has not been...
Three examples on why a claim may be denied are: 1. No preauthorization for non-covered benefits, 2. Processing errors on physicians end and/or no sufficient supporting documentation on why a certain procedure was done for a certain diagnosis, and 3. Incorrect CPT or ICD-9 codes. An EOB can prove a certain service or procedure was denied for the reason specified will be included in the “remarks or description field” in the
The senior counselor met with Yommala to address a concern about patient #3944 medical order dated 10/2/2017: “Patient having surgery today to place stents near the heart. HCRC was not aware and was not given any prior paperwork. Pt informed needs to return with discharge paperwork prior to dosing.”
It is not clear if the adverse risks, of the requested health care service, are substantially increased over those of available standard health care services or treatments, because there is not enough data on which to make an assessment of such
medical practices are beneficial; they are done to cure people from illness and to save
Providers must act in the best interest of the patient and their basic obligation is to do no harm and work for the public’s wellbeing. A physician shall always keep in mind the obligation of preserving human life. Providers must communicate full, accurate and unbiased information so patients can make informed decisions about their health care. As a result of their recommendations, providers are responsible for generating costs in health care but do not generate the need for those expenses. Every hospital has both an ethical as well as a legal responsibility to provide care, even if the care may be uncompensated.
With the high degree of variations in health care, patients can be under or over treated or even treated with the wrong treatment for their illness. These unwarranted care techniques can be categorized into three different situations. The first category of unwarranted care is the use of evidence or lack thereof, based on other medical care. The way to explain this category is that a care plan for a patient is proven effective without any proof as to why. The example given by Kongstvedt (2007) is the use of beta blockers post heart attack. Beta blockers prove to be effective in nearly one h...
Second, in the page 5/6 in the bill we have received from you, Carle Foundation Hospital suggests us to apply to the “Carle Financial Assistance” program. However, Carle Foundation Hospital already approved 100% of coverage under the program, as the letter we received from you in [date] states.
Reason/Authority/Codes/Characterization: Failed Medical / Physical / Procurement Standards / AR 635-200, Paragraph 5-11 / JFW / RE-3 / Uncharacterized
The carrier has denied coverage of Harvoni 90/400 mg tablets one po qd X 12 weeks as not medically necessary. There is a letter from the carrier to the member dated 01/18/2016, which states in part:
The claimant is a 55-year old filing a DIB claim with an AOD of 12/18/2015 due to degenerative disc disease (DDD), anxiety, depression, tachycardia, a heart murmur, knee pain, arthritis, high blood pressure, phobias, diabetes, insomnia, a pinched, nerve, hands, joint, and ankle pain. There
The carrier has denied coverage of treatment with Otezla (Apremilast) as not medically necessary. There is a letter from the carrier to the member dated 04/08/2016 which states in part:
Certainly all of us are interested in providing the best care for our patients, whereas ensuring that they receive quality treatment and in a timely manner. Likewise, to provide optimal care and a decreased length of stay, reducing their cost should also be considered. All of these concerns are known as “Evidence based practices,” or as to say, the use of EBP it must be useful. To be useful, evidence should enable you to do your job better: better outcomes for your patients and better professional satisfaction for you. (Warren 2015)
Queen's Printer, V. B. (2014, October 12). British Columbia Healthcare Services, Canada. Retrieved from http://www.bclaws.ca: http://www.bclaws.ca/civix/document/id/complete/statreg/96070_01
There were three themes which included multiple subthemes. Problems and restrictions subthemes included physical problems, financial problems and socialization problems. The physical problems of the patients were neurological problem such as feelings of being bored and increased anger. Also pain was a physical complaint. Financial problems included the high cost of the pacemaker and for it to be implanted. Socialization problems due to the feeling of being restricted physically causing less social interactions. Theme B, feeling and encounter with pacemaker, subthemes were experience of first encounter, feeling of living with pacemaker, how to get used to pacemaker and satisfaction with pacemaker. Feelings of first encounter consisted of fear, sickness and shock when finding out they needed a pacemaker. Some of the participates did not feel comfortable living with the pacemaker. It