Occipital Neuralgia Surgery

plan, if the more frequent care calls had not helped then the individual may benefit from

- Taking into account the patient physical, social, psychological and spiritual health allow for allow for a more competent and effective patient care.

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.

There is insufficient medical record documentation to determine whether Novolog is medically necessary for the treatment of this member’s

The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the claimant than any available standard health care service or treatment.

Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation and movement. Tongue and uvula are midline. Normal auditory acuity. Normal shoulder shrug.

The carrier has denied coverage of an MRI of the cervical spine as not medically necessary. There is a letter to the member from the carrier dated 11/05/15. In the letter, the carrier states in part: “According to the American College of Radiology Appropriateness Criteria regarding MRI of the cervical spine, MRI may sometime be beneficial in patients with neck pain and no history of trauma and no neurologic deficits. If their neck pain is persistent and they have had findings of degenerative changes on plain radiographs and “following failure of conservative management only in select cases.” In this patient’s case, the patient has self directed her care, having seen specialists and chiropractors without a firm diagnosis

An example is if someone with high blood pressure gets regular checkups, they are less likely to suffer a stroke or heart attack because they are aware of their condition.

The carrier has denied coverage of Harvoni as not medically necessary. There is a letter from the carrier to the member dated 03/09/2016, which states in part:

Over the years, brain surgery has evolved substantially. Looking into multiple types of surgery, surgery is able to be quite unusual. Humans will cut into each other a lot of times in order to get rid of deadly disease and even just to remove excess body fat. The reality that we do not marvel about these on a daily basis shows how advanced surgery has grown over the years. Surgery is a safer and more reliable tool including a necessary component of health care. Previously, the surgeries themselves were brutal from lack of understandings toward anesthesia and none of the tools accessible today with operations forced and traumatic. With the present tools through surgery, brain surgery has changed greatly. This article chosen was aligning with

Choosing Wisely helped in the case of the two services which decreased, the same number of services increased while the rest were unaffected. None of these changes were clinically significant, those that were common before remained common.

For the past couple of years, I have witnessed first hand the effects that trigeminal neuralgia does to the human body. My mother was diagnosed with trigeminal neuralgia in 2010. She was suffering from the pain of the condition for more than two years before she was correctly diagnosed at MD Anderson in Houston, Texas. My mother always explained her pain as worse than childbirth, and that is because she has had four children. It caused my mom to have multiple sleepless nights, an aching jaws, constant and excruciating pain, and in one extreme incident, her job locked while she was chewing causing her to choke and had to receive the Heimlich maneuver. Being that she said it was the worst pain in her life, my family knew it was something more than chronic migraines: which is what one of the doctors she saw in the Rio Grande Valley diagnosed her with.

Moreover, for example, Dr. Khalessi in denying this proposition is fully aware that in the absence of a prior authorization for an overnight, inpatient stay, it is highly unlikely that the hospital will have pre-assigned and/or necessarily have readily available the scarce, highly-trained staff and specialized facilities necessary to deliver timely, urgent care to me should an overnight, post-procedure complication (e.g. a stroke) occur. Accordingly, a post-operative, emergency decision to hospitalize will not necessarily work, and Dr. Khalessi will not re-schedule my surgery until his request for a prior authorization of an overnight, inpatient stay for me is granted.

4. The service does not cost far more than a treatment that is just as likely to work for the problem.”

Some procedures might be a basis for and proceed an open procedure. Such cases can be separately reported with modifier 58. Though the medical record must document the reason and necessity for the procedure.