2012 Irr Testing Physicians

Case # 1 60 year old female with history of DM type II for 12 years, states she is compliant with medications.  Patient is a non smoker.   Patient states she lost 30 lbs following Weight Watchers plan 5 years ago, but gained this back plus 20 additional pounds. Reads nutritional labels but has not recently participated in any weight management programs.   She denies a psychiatric history. 

• Ht 5’4'
• Wt 216 lbs 
• BMI of 37.1. 
• Hgb A1c results :  6.4 to 6.8 over the past year. 
• Medications:   metformin, glipizide and Lantus.  She is also on Zoloft for depression.   

Request is for a laparoscopic adjustable gastric band procedure at a certified level 1 bariatric center with an ASBS certified surgeon.  According to the CMS criteria for Bariatric Surgery (attached to the IRR e-mail) unsuccessful medical treatment for obesity includes which of the following?

Determination for Case # 1

Case # 2 68 year old male with history of Type II DM for 12 years, testing blood sugar four times per day for three months, on insulin for the last 5 years.  He has been in a disease management program for 2 years and completed a diabetes management class three years ago. 

• Self reported glucose 180- 200 range. 
• History of  neuropathy and chronic kidney disease. 
• Medications:  Levemir 50 u bid and metformin 1000 mg bid. 
• A1c has been in the 8-10 range for the last year, and specifically 10.8 in March and 8.6 in July. 
•  CC 41.  C-peptide was 2 ng/ml on the same dates, and fasting blood sugar was 202.  Normal labs for C-peptide Fasting levels range between 1.0–3.0 ng/ml while postprandial levels may range from 1.2 to 3.5 ng/ml. 

Request received from the patient's Endocrinologist for an Implantable Insulin Pump.             After review of the CMS Criteria for Implantable Pump Device (attached to IRR e-mail) Determination for Case # 2

Case # 3 86 year old female with history of actinic keratosis beginning 2 months ago.   Patient complaining that lesion to left shoulder is growing.  She also reports a history of skin cancer 30 years ago.     Dermatologist office notes revealed that multiple actinic keratosis lesions to back, face, chest and arms were destroyed by cryosurgery.  A .5 cm lesion to left shoulder and  a .5 cm lesion to left lower chest were biopsied.     Diagnosis:  Basel cell carcinoma to left shoulder (superficial and infiltrative) and inflamed intradermal nevus to left chest.  Patient was counseled regarding avoiding sun exposure and tanning as well as to use a sun screen > 30 spf daily.  Request from Dermatologist for MOHS surgery to left shoulder.     According to the CMS Criteria for MOHS' Micrographic Surgery (attached to IRR e-mail) the following would be an indication for MOHS' Check all that apply

According to the CMS Criteria for MOHS' Micrographic Surgery only lesions on the face or ear are covered. 

Determination for Case # 3

Case # 4   68 year-old male with Diabetes type II was recently discharged from the hospital following treatment for pneumonia.  He has a long history of diabetes (30 years) with peripheral neuropathy.  During the hospital admission assessment a skin ulcer was discovered on the R leg at the ankle.  The patient reported that the ulcer has been there for a while and was caused by his shoe.  He also reported that at times there was swelling and drainage which he  treated himself.  A wound care RN assessed him during the hospital stay and described the wound as 5 cm wide and 3 cm deep with yellow exudate and classified as Wagner grade II.  Wound cultures were obtained and the wound care RN recommended to start daily treatment.  Blood sugars fluctuated between 150 and 200 mg/dl.  In addition to his medications:  metformin, glipizide, Toprol XL and Lasix he was given regular insulin on a sliding scale.  The daily wound care was started during the hospital  stay and the patient was discharged to home 3 days later with a follow-up appointment in 2 days at the Wound Care Center at the hospital.  Blood cultures were reported as negative.  Hospital discharge codes were as follows:  707.10, 250.70 and 487.0.  Request received from the Wound Care Center for Hyperbaric Therapy due to diabetic ulcer of R lower extremity.  707.10 UNSPECIFIED ULCER OF LOWER LIMB - ULCER OF OTHER PART OF FOOT 250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED Upon review of the CMS Criteria for HBO Therapy the following Criteria were met Check all that apply

According to the CMS Criteria for HBO Therapy CMS will continue to cover HBO if the wound has not shown signs of healing within 30 days

According to the CMS Criteria for HBO Therapy standard wound care for patients with a diabetic wound includes

Determination for Case # 4

Case # 5 70 year old female with history of breast cancer to L breast in 2009. Patient underwent lumpectomy, chemotherapy and radiation in 2009. She recently reported having L rib pain for 2 months. Imaging studies revealed two lesions involving the breast and one to the left lung upper lobe. Tissue Biopsy positive for carcinoma. Request received for PET scan for restaging. Based upon the CMS criteria for PET, what is the appropriate determination for this case

Case # 6 62 year old male with history of type II DM and peripheral neuropathy.  Recently diagnosed with PVD and has a recommendation from his Vascular Surgeon for angioplasty.  Patient states that he wants a second opinion.  The patient reports that he is able to ambulate approximately 20 feet before experiencing pain and weakness to lower extremities.  Rest helps the pain and weakness but he is having to rest for longer periods of time.  He has been using a walker due to concerns from his wife that he might fall.  He has confined himself to one living area in his house and no longer eats his meals in the kitchen because of the distance.  His wife takes his meals to him.   Ht.  5'11" Wt. 182 lbs He is alert and oriented Patient stated that he contacted a network provider and inquired about a power scooter thinking that it would help make him more mobile  around his home.  The DME provider conducted a home assessment and submitted that they recommend a POV for this patient.     Based on the CMS criteria for Power Mobility Devices, what is the appropriate determination for this case

Case # 7 75 year old male with history of DM Type II with neuropathy, hyperlipidemia and hypothyroidism. Complaining of generalized joint pain and stiffness to bilateral lower extremities. He is ambulatory with a rolling walker and has difficulty standing from a sitting position. Was recently prescribed Home Health Physical Therapy x 6 visits which was completed. The Physical Therapist reported the following:                 10-8-2012                                          11-8-2012 Strength      2+                                                 3+ ROM            2+                                                3+ Sit-Stand     fair                                               fair Gait             fair                                              good Continues to have lower extremity weakness and uncontrolled descend from sit-stand. Request for 6 additional Physical Therapy visits received from the home health agency to continue strength and ROM exercise Based upon the CMS Criteria for Home Health, what is the appropriate determination for this case

Case # 8 68 year old female with history of hypertension was recently staying at her daughter’s house. The daughter reported that on two occasions during the night she witnessed the patient having what appeared to be a seizure. She reported that the episodes lasted for some time and that the patient was disoriented upon awakening. The patient denies waking up with her tongue bitten or incontinence and denies having any recollection of the episodes. The patient returned to her home 2 weeks ago where she lives alone. EEG and MRI of the brain were normal. Request for Outpatient video EEG monitoring for up to 72 hours; CPT code 95951.                                                                                                                                                                              Based on the CMS Criteria for EEG, what is the appropriate determination for this case 　 　

Case # 9 　 72 year old male discharged from the hospital 4 days ago. He was admitted to the hospital with symptoms resulting from an infected AICD. He was treated with IV antibiotics during the hospitalization and is now on po antibiotics for 6 weeks. After the 6 week course of antibiotics, the AICD will be removed and replaced. A request was submitted for a wearable cardiac defibrillator. Based upon the CMS criteria for External Defibrillator, what is the appropriate determination