Bacterial Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with necrotizing autoimmune myopathy, polymyositis with quadriparesis, and restrictive lung mechanics due to neuromuscular disease. The patient was noted to have a blanchable red area on her right buttocks that was noted to be associated with moisture. It was noted the patient received skilled physical therapy, with no progress noted. Physical examination findings included severe weakness of all four extremities in both proximal and distal muscle groups, and poor head and trunk control. She was cognitively intact. The patient requires two people for mobility assistance. The patient has requested authorization and coverage for occupational therapy and physical therapy services and a Hill-Rom Envella micro bead sand bed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gastrointestinal pathogen panel laboratory testing rendered on three dates. Based on the available documentation, this patient presented with diarrhea with a history of GERD. The patient underwent gastrointestinal pathogen panel laboratory testing on three dates. In this clinical setting, the initial gastrointestinal polymerase chain reaction pathogen panel performed was supported as likely to have been more beneficial for evaluation of the patient’s medical condition than any available standard therapy. According to the Infectious Diseases Society of America (IDSA) guidelines for acute diarrhea, certain pathogens can cause protracted diarrhea and cannot be detected with commonly used tests but can be found with nucleic acid amplification tests.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for multitarget polymerase chain reaction (PCR) testing for the diagnosis of bacterial vaginosis.As noted in the medical literature, the diagnosis of vaginitis is based on clinical symptoms, pH of the vaginal fluid, and microscopic examination of the discharge. According to the American College of Obstetricians and Gynecologists (ACOG), microscopy is the first line for diagnosing vulvovaginal candidiasis and trichomoniasis. The Centers for Disease Control and Prevention (CDC) also recommend the gram stain as the gold standard for diagnosis of vaginal infections. The CDC advises the use of Amsel criteria if a gram stain is not available.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with a helicobacter pylori infection. The patient reported epigastric pain. The patient had been taking meloxicam for neck pain. The treatment plan included starting pantoprazole and performing Helicobacter pylori testing. The patient underwent stool antigen testing for Helicobacter pylori infection, and the results were positive. The patient has requested reimbursement for Pylera (120 capsule blister pack) received. The Health Plan denied the request and reported the medication at issue was not medically necessary for the treatment of this patient. At issue in this case is whether Pylera (120 capsule blister pack) received was medically necessary for the treatment of the patient’s medical condition. Researchers reported, “Helicobacter pylori (H.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for bacterial infection was denied, the published record says the denial is worth fighting.