Kypho denials

[lobelsteve]

86 y/o on for Wed with acute L1 Fx. Failed meds/brace. Plan for Prolia or Tymlos.
Insurance denying. MRI with STIR intensity. Initially said no PT trial. Now saying not 25% more of VB height loss.

If denied and patient passes away, will encourage lawsuit against insurance.
NNT =15 for kypho to save a life. Ong et al.

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[bedrock]

86 y/o on for Wed with acute L1 Fx. Failed meds/brace. Plan for Prolia or Tymlos.
Insurance denying. MRI with STIR intensity. Initially said no PT trial. Now saying not 25% more of VB height loss.

If denied and patient passes away, will encourage lawsuit against insurance.
NNT =15 for kypho to save a life. Ong et al.

medicare advantage plan? (not regular medicare)

 

[lobelsteve]

medicare advantage plan? (not regular medicare)

Aetna MC HMO/PPO

 

[bedrock]

Aetna MC HMO/PPO

figured as much

I have made it one my primary health care directives to encourage seniors to avoid advantage plans, the same as I recommend exercise, weight loss, and sleep optimization.

Seniors get seduced by advantage plans, but then frequently suffer as result of terrible coverage.

 

[callmeanesthesia]

Thankfully we have a low incidence of such plans, but I tell all those patients that the only advantage in them is for the insurance company.

 

[drusso]

86 y/o on for Wed with acute L1 Fx. Failed meds/brace. Plan for Prolia or Tymlos.
Insurance denying. MRI with STIR intensity. Initially said no PT trial. Now saying not 25% more of VB height loss.

If denied and patient passes away, will encourage lawsuit against insurance.
NNT =15 for kypho to save a life. Ong et al.

They don't care. You're *NOT* having a scientific dispute. You're having a policy dispute. It's NOT about data...it's about dollars.

 

[Ducttape]

i have to agree with drusso.

this isnt necessarily about what is best for the patient. it is about $$$. as are my comments in the ganglion impars thread.

 

[Agast]

Denied on basis of not meeting 30% fracture? Get new X-ray and document fracture appears to have progressed to 30% or whatever the magic number is.

 

[lobelsteve]

24hrs to get required info to them or it gets cancelled and need to be resubmitted.

 

[PinchandBurn]

How much height loss do they want?

Whats the data on the height loss requirement vs edema on STIR and subsequent pain?

Steve, that sounds ridiculous for your patient.

 

[MitchLevi]

Better get that info in ASAP or they'll lock you out for an appeal for 60-90d

 

[lobelsteve]

Submitted all requires info so will hear back tomorrow. Found a plan online with similar criteria that i think they are using.

Bypass: Will admit to hospital on dY of procedure for intractable pain and do kypho later that day.

 

[MitchLevi]

Bypass: Will admit to hospital on dY of procedure for intractable pain and do kypho later that daday.

Bingo. That's doctoring.

 

[oneforfighting]

24hrs to get required info to them or it gets cancelled and need to be resubmitted.

Just had a LESI denied at 4pm Friday with P2P needing to be done by 4pm Saturday

 

[MitchLevi]

Just had a LESI denied at 4pm Friday with P2P needing to be done by 4pm Saturday

Repeat RFA L4-S1 bilaterally denied and P2P must be done by 4PM today. We were notified today at like 230. No % relief from the previous RFA, which was done in 2021 by outside group who didn't document % relief.

 

[lobelsteve]

Repeat RFA L4-S1 bilaterally denied and P2P must be done by 4PM today. We were notified today at like 230. No % relief from the previous RFA, which was done in 2021 by outside group who didn't document % relief.

It was me: 105% relief.
If they roll the 20 sided die at 19/20 they can inflict 5% damage (pain) back to others.

 

[MitchLevi]

It was me: 105% relief.
If they roll the 20 sided die at 19/20 they can inflict 5% damage (pain) back to others.

Critical hit by a Champion Fighter in DnD!

 

[Asclepius186]

86 y/o on for Wed with acute L1 Fx. Failed meds/brace. Plan for Prolia or Tymlos.
Insurance denying. MRI with STIR intensity. Initially said no PT trial. Now saying not 25% more of VB height loss.

If denied and patient passes away, will encourage lawsuit against insurance.
NNT =15 for kypho to save a life. Ong et al.

Force them to do the required PT and the fracture will progress to > 30%. That must be their intention. Bingo

 

[callmeanesthesia]

Force them to do the required PT and the fracture will progress to > 30%. That must be their intention. Bingo

6 weeks PT. Kypho denied due to > 6 weeks since initial fracture.

 

[PinchandBurn]

6 weeks PT. Kypho denied due to > 6 weeks since initial fracture.

Curious. How is PT going to help a fracture?

Also wouldnt doing PT increase the pain of fracture and if PT pressed on it , couldnt it even worsen???

 

[callmeanesthesia]

Curious. How is PT going to help a fracture?

Also wouldnt doing PT increase the pain of fracture and if PT pressed on it , couldnt it even worsen???

I wasn’t suggesting PT, just suggesting the next line of denial from insurance. Although I do get my VCF patients into PT as soon as tolerating. Aquatic PT if their physical ability is very limited. Not to help with pain but to limit deconditioning.

 

[MitchLevi]

Extension-based HEP longterm

 

[Tboned]

interesting discussion as I too had a kyphoplasty denied today for not having the patient participate in an “active exercise program”.
I ended up addendng my note to say that active exercise program was contraindicated given compression fracture progression (which has happened since see was seen in our orthopedic urgent care) but will engage with pt/exercise program when appropriate and resubmitted.
See what happens

 

[Ferrismonk]

Repeat RFA L4-S1 bilaterally denied and P2P must be done by 4PM today. We were notified today at like 230. No % relief from the previous RFA, which was done in 2021 by outside group who didn't document % relief.

Not saying this problem is your fault, but this could have been avoided by you documenting the patient's stated relief (just guessing here, but likely they'll say 80% for greater than 6 months) during your office visit in which you scheduled the RFA.

 

[Ducttape]

for RFA, it should be 50% for 6 months.

fwiw, cant document any number other than 6 months.

yes, got denial because of documenting 8 months instead of 6...

 

[lobelsteve]

Update: Patient in severe pain, still denied by insurance for kypho scheduled for 330PM today. Heading to ER for admission.

 

[buddababa]

Update: Patient in severe pain, still denied by insurance for kypho scheduled for 330PM today. Heading to ER for admission.

i doubt hospital will get paid for kypho?

 

[lobelsteve]

i doubt hospital will get paid for kypho?

Thinking similar criteria.

 

[drusso]

Update: Patient in severe pain, still denied by insurance for kypho scheduled for 330PM today. Heading to ER for admission.

Make sure you have psych clearance because pain is both a sensory and emotional condition.

 

[lobelsteve]

Make sure you have psych clearance because pain is both a sensory and emotional condition.

3. Multidisciplinary team consensus (ALL are required)
a. Referring physician (e.g., rheumatologist, endocrinologist)
b. Treating physician (i.e., performing the PVA)
c. Radiologist
d. Neurologist

 

[PainMD23]

Just had a LESI denied at 4pm Friday with P2P needing to be done by 4pm Saturday

This happens all the time. I love it when PA is denied, then insurance company notifies Friday afternoon. Then, requires an appeal or P2P to be done within 48 hours. I have been on call multiple times for my practice when this happens-- Friday 5 o'clock call notifying the office that the opioid that grandma has been on for 2 years suddenly denied. Need to complete PA or P2P within 48 hours (not business hours mind you, but within 48 hours). I have completed these PA's over the phone to accommodate the patient. I always felt this practice was absolutely abusive towards physicians, but I didn't want to leave the patient hanging.

 

[TIVAndy]

once again medicare disadvantage plans strikes again. i had a good one today. L5-S1 TFESI denied today. in the note patient stated today pain is 1/10 but when active or moving around pain is 6-7/10. medicare HMO denying injection since she documented 1/10 pain at this moment, ignoring the increased pain with activity.

 

[Ducttape]

happens all the time.

document "average pain over the past week >6"

i usually add "told nurse pain today 1/10, but just got up". at 3pm.

with a lot of my patients, that is unfortunately true...

 

[Gauss]

figured as much

I have made it one my primary health care directives to encourage seniors to avoid advantage plans, the same as I recommend exercise, weight loss, and sleep optimization.

Seniors get seduced by advantage plans, but then frequently suffer as result of terrible coverage.

I've also been advocating to my patients against advantage plans for the past decade... BUT most of the retirement buyouts during the pandemic offered these plans giving 10 years of health & dental coverage to those >65 and it is understandable that they took them

 

[painfree23]

these stories infuriate me as I deal with similar issues daily and have no one to vent to. I vent to the patients so they are aware of this bs. 99% don’t have any idea that their insurance is capable of this bs. I think we should start a movement…someway to document these things for propublica.

 

[lobelsteve]

If only there was a bill before congress. (Cue drusso)