A five-year-old boy comes into the emergency room after falling out of a tree. The doctor has an x-ray ordered after the boy complains of pain in his ankle. The x-ray shows that his ankle is fractured. The doctor then applies a full-length leg cast to the entire length of the boy’s leg.
Define medical necessity in your own words. Does the diagnosis support the services ordered? Defend your answer. If not, supply the appropriate service for the diagnosis.
Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:
For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
In accordance with the generally accepted standards of medical practice
Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease
For these purposes, "generally accepted standards of medical practice" means:
Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
Physician Specialty Society recommendations
The views of physicians practicing in the relevant clinical area
Any other relevant factors
Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents
A five-year-old boy comes into the emergency room after falling out of a tree. The doctor...
A patient comes in for evaluation of a right ankle injury after playing a game of basketball and falling after turning his ankle. He is in extraordinary pain and the physician has ordered an x-ray using the diagnosis code of S99.911A for unspecified right ankle injury, initial encounter. The x-ray comes back with a finding of a displaced fracture of medial malleolus of the right tibia. At the follow up visit with the patient, the physician continues to use the...
A 10-year-old boy presents to the emergency department complaining of right-sided chest pain after being in a motor vehicle accident. The boy complains that pain is sharp, and he is very short of breath.. He has tachycardia and tachypnea, and is diaphoretic. His trachea deviates to the left, and he hanse breath sounds over the right lung. A non-rebreather mask is placed on the patient, and a STAT chest radiograph is taken. What doses the chest radiograph show?
Case Study 5 An 11-year-old boy was brought to a hospital in California after falling; he had extensive bruising on his left side and lacerations on his elbow and knee. His mother said that he loves the outdoors and they live adjacent to a wooded area. He spent much of his free time exploring the woods and climbing tress. His injury resulted from one of these tree-climbing episodes. The boy has no broken bones. His injuries were treated, he was...
Mr. Lewis is a 88-year old man brought to the emergency room by his daughter after finding him in his bedroom, lying on the floor beside his bed. Mr. Lewis is in obvious pain. He is wheeled into the ER by his daughter. He is moaning and rubbing his right leg. Pausing after every few words to catch his breath, he tells the nurse, “My leg is killing me. It keeps tightening and releasing. I cannot stand on it. It...
Case scenario Mr. C, 50 years old, is an amateur soccer player who regularly plays with his friends over weekend. He has chronic anterior right hip pain and weakness over his groin region for 5 years. One day, when he was playing soccer, he was injured by another player who crushed on him from lateral side of his left leg. Then, he fell down on the grassland after twisting his left knee and ankle due to the crush. He started...
On a cold February day, a 6-year-old boy was brought to the emergency room by his frantic mother because he had passed red urine and looked very pale. He was a normal, active boy, and in fact has played out in the snow the day before. He had the "flue" for about 1 week about 10 days before this episode. He had not received any medication except acetaminophen. On admission, his CBC values were: WBC 12.0 x 10^9L, RBC 3...
A 16-year-old boy arrived at the Emergency Department (ED) after collapsing during a 3-hour practice at summer football camp. The patient had the required physical examination prior to attending the camp, and there were no concerns or physical restrictions documented. He received intravenous (IV) fluids in the ambulance, and is awake upon arrival to the ED. He complains of thirst and dizziness. He has not voided since prior to practice, has dry mucous membranes and tenting. The patient’s pulse is...
Mr. Lewis is a 88-year old man brought to the emergency room by his daughter after finding him in his bedroom, lying on the floor beside his bed. Mr. Lewis is in obvious pain. He is wheeled into the ER by his daughter. He is moaning and rubbing his right leg. Pausing after every few words to catch his breath, he tells the nurse, “My leg is killing me. It keeps tightening and releasing. I cannot stand on it. It...
G.N., a 65-year-old African American man, was admitted to the hospital emergency department with partial-thickness burns that involved his face, neck, and upper trunk. He also had a lacerated right leg. His injuries occurred about 36 hours earlier when he fell out of a tree onto his gas grill (which was lit) while trimming tree branches. Subjective Data • Complains of a slightly hoarse voice and irritated throat • States that he tried to treat himself because he does not...
A 40-year-old male with a history of intravenous drug use comes to the emergency room because of a rash and fever. In addition, the patient is complaining of a several-day history of malaise, fatigue, fever, headache, and a sore throat. Physical examination reveals a moderately ill-appearing male with a temperature of 101.6°F. He has a blanching erythematous, macular-papular rash evident over the trunk, back, and upper and lower extremities. In addition, his throat shows enlarged tonsils and broad-based ulcerations on...