Plan Case Study – Using CAVO for Medical Necessity Reviews

/ Post-Pay Reviews / Medical Necessity Reviews /
 

THE CASE

 

Patient is a 50-year-old male who had a neurostimulator placed for pain control related to chronic back pain and right lower extremity numbness. He is a former police officer who was injured while on duty with nine subsequent back surgeries resulting in post laminectomy pain syndrome. He now requires use of a cane to walk and wears a brace on his right leg due to the periodic loss of balance caused by the numbness.

Patient has a 367-page medical record. This case has been automatically flagged to be reviewed due to this procedure qualifying as high-dollar (more than $20,000). According to this patient’s policy, certain criterion must be met in order for insertion or replacement of spinal neurostimulator pulse generator or receiver to be covered.

The patient must have met all of the following criteria prior to the procedure being performed.

  • Criteria #1: Physical Exam and Psychological Exam were performed pre-operatively; patient was cleared for surgery from a psychological standpoint.
  • Criteria #2: There are no untreated existing drug addiction problems.
  • Criteria #3: More conservative methods of pain management were tried and failed.
  • Criteria #4: There is documented pathology (objective data) that explains the reason for the patient’s pain.
  • Criteria #5: There was a significant reduction in pain (50% or more) with a 3 – 7 day trial of percutaneous spinal stimulation.
 

CASE REVIEW STEPS
DETAILED FOR CAVO

 

Step 1: Verify surgery occurred.

Search operative report – which renders this report as the first result. Let’s scroll to the end of report to verify the surgery end time (or find a note that it was not completed). This information is found on page 154.

 

Step 2: Begin checking Criteria #1, starting with verification that physical and psychological exams were performed pre-operatively.

Search consultation to be sure find the pre-op physical exam (versus post-op).

Notice that there is a pathology for patient’s pain – which supports Criteria #4.

Criteria #3 for trying more conservative pain management methods is answered on same page of this report.

Above this paragraph, it states that the patient underwent a trial for 6 days with a 75—80% improvement, which satisfies Criteria #5.

 

Step 3: Continue checking Criteria #1, now verifying patient was cleared for surgery by psych.

Search psych. Let’s read all of the consult notes, after which we know that there is no mention of being cleared by psych for this surgery. While Criteria #2 has not yet been verified, there is no need to continue reviewing this case, as all criterion must have been satisfied pre-operatively.

 

RESULTS WITH CAVO

 

Previous Medical Necessity Reviews Process

Search: Manually index medical records; create a worksheet template; and read each progress note, consult, etc. for medical necessity determination.
Time Investment: 160 minutes

 

CAVO Medical Necessity Reviews Process

Search: Three online searches, as outlined above. Note: different search logic can also produce the same determination but with varying numbers of searches and time investments.
Time Investment: 50 minutes

 

Finding

There is no documentation that the patient had a consult with a psychologist or psychiatrist pre-op; therefore, patient does not meet criteria for this procedure. Claim will not be paid.

 

 Productivity Lift: 320%