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Our goal is to bring our readers the latest information and updates in utilization review.
The HOT Topic for this week is Myringotomy and Tympanostomy Tube. The PRC for this procedure was recently updated to reflect changes related to adult patients.
The Compliance Corner addresses the ongoing debates between the insurance industry and state regulators over the definition of what spending can qualify as medical care under the new health law. Funding for Utilization Review may fall under medical or administrative costs, impacting not only insurance carriers, but many external UR companies, as well.
 August is National Drowning Prevention Month.
Linda Sheff, MBAEditor |
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| Today's Hot Topic: Myringotomy and Tympanostomy Tube |
The American Academy of Otolaryngology (AAO) - Head and Neck Surgery notes that by the age of five, nearly every child has experienced at least one ear infection. Most either resolve on their own or are effectively treated by antibiotics. Sometimes, ear infections and fluid in the middle ear may become a chronic problem leading to other issues such as hearing loss, behavior, and speech problems. In these cases, insertion of an ear tube by an otolaryngologist may be considered. Ear tubes, also called tympanostomy tubes, myringotomy tubes, ventilation tubes, or PE (pressure equalization) tubes, are tiny cylinders surgically placed through the tympanic membrane to allow air into the middle ear.
Ear tubes are considered when there are repeated middle ear infection (acute otitis media) or  hearing loss caused by the persistent presence of middle ear fluid (otitis media with effusion). These conditions are most commonly seen in children, but can also occur in teens and adults where they can lead to speech and balance problems, hearing loss, or changes in the structure of the tympanic membrane. The AAO site states that more than half a million ear tube surgeries are performed on children each year. This makes it the most common childhood surgery performed with anesthesia. The average age of ear tube insertion is one to three years old.
A secondary purpose for ear tubes is to provide an alternate route for the exit of middle ear fluid. Removal of ear fluid restores the normal transmission of sound across the middle ear to the inner ear. Both children and adults with otitis media with effusion (OME) can bebefit from this procedure, when criteria are met.
Visit the PRC guideline for Myringotomy and Tympanostomy Tube to see the latest crtieria for medical necessity for this procedure applicable to both children and adults. |
| Compliance Corner: Medical Loss Ratio (MLR) Debate |
The Patient Protection and Affordable Care Act adds costs for "activities that improve health care quality" to the costs for "reimbursement for clinical services provided to enrollees" when calculating medical loss ratios (MLRs). MLRs are aimed at determining how much of the carrier's premium will be directed toward payment of health care claims versus administrative costs. Under the recently passed federal act, insurers will have to spend 80 percent of the premiums they collect on health care and the remaining 20 percent on administrative costs. For larger carriers the split will be 85/15 percent. Therefore there is a storm brewing over where to include "utilization review" in the medical loss ratio (MLR) calculation. Should it fall under the health care claims column or under administrative costs? The AHA, American Medical Association, and Federation of American Hospitals recently urged the National Association of Insurance Commissioners to exclude from the medical loss ratio's health care quality improvement category "all utilization review activity" citing that it has nothing to do with quality improvement. However, lobbyists for other carriers are arguing that utilization review should be included under the health care side of the ratio. NAIC is tasked by the Department of Health and Human Services with drafting the MLR standards, which are expected by the end of the summer.
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| PRN Case Files: Acromegaly Follow-up |
A 63-year-old male is being re-evaluated for a past history of acromegaly. The patient was first seen in 2001 with a 16mm pituitary tumor and clinical and biochemical features of acromegaly. He had a very elevated growth hormone level of 23 and a very elevated IgF-1 level of 970. He underwent a trans-sphenoidal surgery to remove the tumor and postoperatively had a remission of symptoms. He is now nine years post operations and has had no interval endocrinology follow up or studies. Clinically, he has new symptoms of sexual dysfunction and decreased libido. On physical examination, he has stable changes of acromegaly. It is noted that he has a large tongue, prominent swelling of the soft tissues, and significant arthritis in the hands. The attending physician wants to do an MRI as part of the workup of this patient.
The reviewing endocrinologist determined that the requested MRI of the brain and pituitary gland is medically necessary and appropriate in this clinical setting. The request is consistent with most published guidelines, which usually include as part of the criteria, follow-up imaging for primary brain tumors and post-intracranial procedures. Noted experts in acromegaly report that cure rates of patients with growth hormone producing pituitary tumors are about 50 percent in those who have a tumor of 10mm or greater (a macroadenoma). The cure rate is defined as the basal growth hormone level of less than or equal to 2.5. It is even less for giant tumors or tumors with extension beyond the confines of the pituitary gland. Standard treatment recommendations include annual clinical biochemical and MRI evaluations after surgery. Acromegaly is a rare disease and complete resection of large macroadenomas rarely is achieved. Pharmacologic treatments and re-operation in certain cases may be necessary. Therefore, it is necessary to follow pituitary tumor patients with occasional MRI studies. Whole brain MRI follow-up, with attention to the pituitary gland, to re-evaluate the tumor is appropriate and medically necessary.
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| Care Management News |
Bottled Tea May Not Produce Health Benefit
 People who buy commercial bottled tea may not be getting the healthful doses of antioxidants, or poylphenols, they expect, U.S. researchers found.
Although experts have long suspected alcohol to be a breast cancer risk factor, new research suggests it's most strongly linked to certain breast tumor types.
U.S. government researchers working to find ways to treat the highly deadly Ebola virus said on Sunday a new approach from AVI BioPharma Inc (AVII.O) saved monkeys after they were infected.
Click on the underlined title of each article above to see the complete report. |
 Albert G. Sheff, M.D. President/CEO - Physicians' Review Network, Inc.  
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