2012 Volume One Hundred Six | |
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| Greetings! |
Hot Topics in Care Management is PRN's newsletter for latest news and interesting features related to utilization review.
In this issue, we are reviewing a PRC that was introduced about a year ago. The topic is the non-implantable pelvic floor stimulator. It appears that there has been little change in this topic, although the PRC has been modified slightly to reflect current coverage issues.
How often do you see cases come for utilization review where the request for surgery seems premature? Today's clinical case is an example of this situation.
The Compliance section has been split into 2 articles. One is an update regarding the federal government's attempt to provide review of state workers' compensation systems. The other is the Supreme Court's review of California's attempt to lower medicaid reimbursements.
Linda Sheff, MBA
Editor
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Today's Hot Topic: Urinary Incontinence Treatments/Non-implantable Pelvic Floor Stimulator
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There are three major treatment categories for urinary incontinence: pharmacologic, behavioral, and surgical. A complete evaluation and urodynamic testing should be completed before treatment is intitiated. The appropriate treatment will depend on the type of incontinence present.
Pharmacologic treatment includes anticholinergics and tricyclic antidepressants for urge incontinence. Estrogen and alpha-adrenergic drugs are appropriate for stress incontinence.
Refractory detrusor instability in urge incontinence is treated with cystoplasty or bladder denervation procedures. Hypermobility is treated by retropubic suspension, needle bladder neck suspension, or anterior vaginal repair. Intrinsic sphincter deficiency is treated with the sling procedure, artificial sphincter, or periurethral bulking injections. Obstruction requires surgical removal of the obstruction or catheterization.
Behavioral techniques include bladder retraining, pelvic muscle exercises (PMEs) or Kegel exercises, biofeedback therapy, vaginal weight training, and pelvic floor electrical stimulation. Biofeedback is appropriate for patients who failed a documented trial of pelvic muscle exercise training. One to three sessions are usually sufficient for training and transition to a home exercise program.
 Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. The methods of pelvic floor electrical stimulation vary in location, stimulus frequency, stimulus intensity or amplitude, pulse duration, treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use and between clinic and home settings.
Non-implantable pelvic floor electrical stimulation is only effective for patients with minimal to moderate anatomic defects. Training usually requires only one office visit for education and demonstration of the device.
Read more and see coverage positions for several health insurance carriers by clicking:
PRC Guideline
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| Compliance Corner: Update: Federal Commission to Review State Workers' Compensation | |
Do you remember this bill from 2011? Representative Joe Baca, Democratic Representative from California, introduced legislation (HR 263) to establish a national commission to review the workers' compensation laws of the fifty states. HR 623 will establish a "National Commission on State Workers' Compensation Laws." The commission will be charged with assessing state compensation in terms of amounts, timeliness, and quality of medical care. This bill is still in Committee.
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| Compliance Corner: Supreme Court Sends Back to Lower Court Medicaid-Cuts Case |  The U.S. Supreme Court sent back to a lower court a case on whether Medicaid recipients and medical providers can sue California for cutting reimbursement rates in the healthcare program for low-income Americans. Justice Stephen Breyer said the case was sent back to a U.S. appeals court based in California to determine whether the recipients and providers may sue in light of the changed circumstances of the federal government's approval. In sending the case back, the justices set aside a ruling by the appeals court that had blocked the cuts for violating federal law. In 2008, California lawmakers decided to slash Medicaid payments to doctors, hospitals and other medical providers to help reduce the state's massive budget deficit. The providers sued to stop the cuts from taking effect on the grounds it would violate federal law. The cash-strapped state said the cuts of up to 10 percent would save more than $700 million. The state and the Obama administration argued that only the U.S. government can enforce the federal law and private citizens have no right to sue. Link to Case ( American Bar Association) The Supreme Court cases are Douglas v. Independent Living Center, 09-958, Douglas v. California Pharmacists Association, No. 09-1158 and Douglas v. Santa Rosa Memorial Hospital, No. 10-283. |
| PRN Case Files: Meeting Criteria for Endoscopic Antrostomy and Turbinate Reduction |
A 49-year-old male presents with a history of reflux and sinus problems with postnasal drainage. The patient was noted on the initial date of examination to have intranasal endoscopic examination consistent with deviation of the nasal septum and swollen maxillary meatus. The patient has a history of septoplasty. The physician ordered additional testing to include allergy testing and a CT scan. The patient was then begun on medical therapy with AcipHex and Flonase nasal spray. Two days later, a CT scan of the sinuses was done that showed primarily mucosal thickening and obstruction within the maxillary sinuses. The attending physician then recommended that the patient undergo bilateral endoscopic antrostomy and turbinate reduction surgery. An antrostomy is the name of the procedure to clear the sinus opening.
The reviewing physician concluded from the information provided on this patient, that the requested procedures are not medically necessary, as the patient has not had an adequate course of medical therapy for the chronic sinus disease, as well as nasal obstruction. The patient, although begun on AcipHex and nasal steroid, had only two days of therapy prior to the CT scan with the abnormal findings. In addition, although allergy testing was anticipated for the patient, it was not performed prior to consideration of surgical intervention. This patient does not meet criteria for surgical intervention, as there has not been an adequate trial of conservative teratment. The patient should have optimal medical therapy prior to consideration of surgical intervention.
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| Care Management News |
Electronic health records have long been touted by Democrats and Republicans alike as a sure-fire way to lower health spending. When doctors have easy electronic access to a patient's records, advocates argue, they are less likely to order the duplicative and unnecessary tests that drive up the cost of health care in America.
 Kids who are the youngest in their class are significantly more likely to be diagnosed and treated for ADHD, a new Canadian study has found.
A number of branches of research have shown that younger kids in a class often struggle keeping up with their older peers - particularly in the earliest grades.
Lower Stress Fracture Risk in Girls Linked to Vitamin D Intake
Girls who consumed the most vitamin D had the lowest risk for stress fractures, but dairy consumption did not reduce the risk, and calcium actually increased it, according to results from a new study published online March 5 in the Archives of Pediatrics & Adolescent Medicine.
Three young people have been hospitalized with kidney failure and a dozen others sickened in Casper, Wyoming, in an outbreak linked to a batch of the designer drug Spice, authorities said on Friday.
Click on the underlined title of each article above to see the complete report.
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 Albert G. Sheff, M.D. Founder - Physicians' Review Network, Inc.
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