Medical Necessity Updates

Off-Label Avastin Use For Wet Macular Degeneration

Researchers have determined that off-label use of Avastin is an effective treatment for wet AMD, the leading cause of blindness in people over 50 years old. Although physicians and researchers are debating the effectiveness of Avantis versus Luncentis, a drug that costs 40 times more than Avastin, some ophthalmologists consider the two to be equal.

Lyme Disease: What’s the Benefit of Antibiotic Therapy for Long-Standing Symptoms?

 

Battling Childhood Obesity with Bariatric Surgery

With childhood obesity becoming an ever-present epidemic, the issue of patient qualification for bariatric surgery needs to be revisited. Recent data shows that nearly 17 percent of US youth between the ages of six and 19 are considered overweight.

9 Hints / Telltale Signs that Say You Need an IRO

Using an IRO is an efficient and defensible way to manage a health plan properly for both the insurer and the patient. As unbiased advocates for managing healthcare costs, IROs ensure that every claimant is properly served, every time. Read more for nine hints and telltale signs that you need an IRO.

Diagnosing and Treating Circadian Sleep Disorders

 

When Renal Artery Stenosis Screening is Medically Necessary

 

Avastin (Bevacizumab) Therapy in Oncology

 

Management and Care of Acute Coronary Syndromes

Atherothrombosis is the leading cause of death worldwide and accounts for 52 percent of all deaths. Over 55 million people worldwide died from atherothrombotic disease in 2000. In 2004, there were 1.6 million of hospitalizations for ACS, 700,000 for UA and 900,000 for myocardial infarction (MI). Of these, about 30 percent presented ST-segment elevation in the electrocardiogram (ECG).

Developmental Delay: How to Diagnose, Plan Exclusions

Developmental delay is a term applied to a wide range of disorders, including mental retardation, motor delays, developmental language delays, developmental coordination disorders, autism spectrum disorders and global developmental delay. Before modern imaging and genetic studies, the term described any child not achieving developmental milestones and in whom a medical diagnosis had not been identified.

Improving Utilization Review Accuracy

Read how an independent review organization effectively integrates into a medical management workflow and ensures accurate utilization review.

When Is Eyelid Surgery Medically Necessary?

 

What to Consider for Sleep Apnea Treatment

Because sleep apnea can be caused by a handful of different factors, treatment options vary. Understanding the cause of the sleep apnea is the first step towards deciding the best treatment option for the patient.

Understanding FDA Approval for Medical Devices: Vest Airway Clearance System

While FDA approval for a drug product suggests safety and efficacy, the same approval for medical devices does not. Approval for a device only assumes the manufacturing method is reliable and that the device is similar to another on the market. One such device is the Vest Airway Clearance System.

Ten Reasons To Use An Independent Review Organization (IRO)

Increasingly, healthcare providers, insurers, medical directors and case managers are turning to Independent Review Organizations (IROs) to collaborate on the decision-making process for medical claims. At question, however, is when in the decision-making process does this make the most sense? Here are the top 10 signs to identify when to bring in an IRO:

Streamlining Sleep Apnea Diagnoses

Rather than performing multiple, separate diagnostic and therapeutic tests for sleep apnea, doctors are now combining the two into a single study.

Removing Varicose Veins for Healthy Legs – Is It Covered?

There a multitude of causes that contribute to a patient's inclination to develop varicose veins. Covering the removal of varicose veins for healthy legs requires specific requirements throughout a patient's screening, diagnoses and treatment process.

Obesity Letter

Until recently, not all insurance plans have covered gastric bypass surgeries. However, as obesity reaches an increasing level of crisis in the country, this practice is changing.

Managing Evidence-Based Self-Insurance Plans

How do the management companies, without a full medical panel on staff, decide that treatment decisions are based on proven medical evidence each and every time? How do these companies ensure that they are staying up-to-date with the latest medically approved treatment options? The answer: An Independent Review Organization.

Making ERISA and DOL Appeals Easier and More Cost-Effective

Simply stated, under DOL and ERISA, when a benefit plan denies a claim, the claimant has the right to appeal a decision and the review of the appeal must be made by someone who’s at “arms length,” is a like specialist and who was not involved in the initial review process. Turning to an independent review organization for this review assures compliance and eliminates risks for payers.

Make Your Next Review Easier (and possibly save money)

If you´re a claims manager, case manager or utilization management nurse and are sending cases to an IRO for independent review, here are four important tips that can make your next review easier—and maybe less costly.