The patient is an 84-year-old gentleman who presented to the ED because the J-tube had fallen out. The patient had a subtotal gastrectomy Roux-en Y and gastrojejunostomy with D tube adenoidectomy and placement of jejunostomy tube on 12/14/2016 for gastric tumor. The patient was discharged to a rehabilitation and presented because the jejunostomy tube had dislodged. It actually had been pulled out the morning of presentation. The patient was clinically stable and was admitted inpatient. The patient was already tolerating oral feedings and basically stayed overnight in the hospital and was discharged. We attempted to request an outpatient order on this patient and never received it, therefore the admission is
There was no documentation dated after the procedure performed on August 28, 2014, or before the date of service billed in this appeal. The medical documentation did not highlight acute symptoms warranting the need for the service in question.
After review of the clinical information provided by Kings Brook Jewish Medical Center, the Medical Director has denied your admission to Kings Brook Jewish Medical Center. It was determined that the clinical information did not justify an inpatient stay. Acute inpatient hospitalization was not medically necessary. You are a 26 year old male who presented to the emergency room with complaining of difficulty swallowing. You experienced throat pain, severe right jaw pain and edema (fluid) for the duration of 2 days prior to your hospital admission. You had an intermittent toothache for the past 2 years, but did not see dentist. You had a temperature of 97.7 at the time of admission. Your exam showed that you had tonsils that was noted as moderately red and swollen with
History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and
At this point in time, I feel that the patient is gravely disabled, that he cannot provide food, shelter, or clothing for himself nor make decisions in regard3 to his medical or financial affairs in his best
I am a DNP resident who is assisting emergency department physician to take care of this patient.
During this reporting period there have been no appointments to attend. Mr. Rife continues to work without any restrictions. He has pain to the left arm which he is tolerating until the surgery date on 5/3/17. The post operative appointment has not been scheduled yet. Mr. Rife wants to miss as little time as possible from
PO had no service plan open in this dimension due to participating only one week in treatment. PO does not have any biomedical conditions that could interfere with
While your son was in the ER diagnostic studies of laboratory tests (chemistry panel, complete blood count and urine analysis) were completed. Your son also received IV fluids and Tylenol. An abdominal ultrasound was performed and the results noted “appendix is not visualized and appendicitis cannot be excluded on the basis of this exam.” At this point it was medically necessary for your son to receive a CT scan to rule out appendicitis which can be a life threatening illness. After monitoring, Caspian was able to tolerate fluids and his condition had resolved. You were provided with discharge instructions that stated “there are many causes of abdominal pain. Pain can mean a serious problem (such as appendicitis) requiring surgery, or an innocent problem (such as a viral infection) that goes away on its own. Often time must pass to determine the cause of your pain. The ED physician does not feel that hospitalization is necessary at present. Since many different things can cause stomach pain, further exams, lab tests or X-rays may be needed. You will need to watch for any new symptoms, or if your [son’s] condition gets worse.” A Nurse Practitioner did see your son, but a pediatric physician had reviewed the Nurse Practitioner’s plan of care, was available for consultation, and agreed with clinical impression, plan and
Based upon the information provided, it has been determined that: the requested admission/day(s) is not/or are no longer medically necessary because: After review of the clinical information provided by North Shore University Hospital -Manhasset, the Medical Director has denied your admission to North Shore University Hospital - Manhasset. It was determined that the clinical information did not justify an inpatient stay. Acute inpatient hospitalization was not medically necessary. You are a 58 year old male, with a pre-authorized outpatient procedure on 09/02/2015 for a cardiac catheterization with an intervention, which was converted to an inpatient level of care. Based on the Interqual criteria (a decision based program to determine medical necessity) this procedure does not require an inpatient level of care, therefore, it does not meet criteria.
A week after initial admission, the patient is on the medical surgical floor recovering from his transverse colostomy five days ago. At 1200 vital signs are as follows, temperature 99.1; pulse 96; respirations 18; blood pressure 141/69; pulse ox is 94% on 1L NC in AM. The patient appears acutely ill and lays in bed with his eyes closed even when family comes into the room to check on him. He is alert and oriented to person, but not place or situation. He appears lethargic and is slow to respond to questioning, this appears to be due to recent administration of pain medication. Pupils are equal round and reactive to light and grips are week bilaterally in hands. Abdomen is firm, distended, and non-tender. Colostomy site appears to be
After many calls to Dr. Vanderjagt’s office, a prescription order was obtained and faxed to Hope Network. I have spoken with Hope Network and confirmed that they are able to accommodate the therapy recommended by the FCE. I have made many calls to Hope Network working on providing them the open claim letter and also the FCE. On 10/13/17 I scanned and faxed the FCE and open claim letter again and confirmed they received it.
The primary problems for my patient, E.R., were his feeding issues and his infection. MD orders concerned his cardiac issues, feedings and antibiotics, working to fight his infection and facilitate his feeding. MD orders consisted of measurements to evaluate his growth such as height, weight, and head circumference. Orders to facilitate growth, which included the placement of a NG tube to aid in feedings as well as a future order to get a G-J tube place (which would help with the absorption of nutrients). They implemented a new order during morning rounds, which was a continuous feeding via NG tube. Ultimately it was a trial because of his history of feeding intolerance but it was better to try than wait out for his possibility of a G-J Tube
This patient also had a gastrostomy tube placed due to being unable to tolerated feeding by mouth. He receives formula feedings through this tube for nutrition. Along with this patient coming in due to undetectable Tacrolimus levels, he has also come in for Failure to Thrive. With this, it means that he was either incorrectly being fed or not being fed at
My last resort was to offer the GP out of hour’s service but this was also refused by my patient.
Interacting with these patient taught me about the challenges they face establishing reliable care. They are often assigned to one of the few clinics in town who will accept such challenging patients for such low reimbursement. Getting to the clinic may require arranging transportation that can deliver the patient to and from an office visit or referral. Often the clinics these patients are assigned to are overcrowded and may not be able to see the patient for weeks or even