Describe the Beneficiary's Medical Profile (follow Optimal's writing guidelines) *
The beneficiary was 67 year old woman with a history of chronic venous stasis and chronic non-healing leg wound. She went to the Emergency Room (December 27, 2013) complaining of bilateral lower extremity swelling (cellulitis) and pain. She had a severe infection (septic shock), was admitted to the hospital, was seriously ill, and “ended-up with bilateral above-knee amputation.” She developed multiple problems, including kidney failure (required dialysis), and cardiac problems (atrial fibrillation). She had a history of total left hip replacement.
After her hospital stay she was transferred to a rehabilitation facility (January 27, 2014). Per a medical …show more content…
Date of service: January 03, 2015 (Delivered on April 3, 2014).
The services at issue are reasonable and necessary *
Reasonable yes,
Necessary: unknown if it was as beneficial as other services (manual wheelchair)
Do you agree or disagree with the QIC's conclusion regarding the medical necessity of the services at issue? *
Yes
Please justify your agreement or disagreement with the QIC's conclusion regarding the medical necessity of the services at issue (follow Optimal's writing guidelines) *
I AGREE with the QIC’s decision to deny payment for the power wheelchair. The information in the records submitted failed to support the beneficiary’s medical need for such equipment.
There was insufficient information about the beneficiary’s problems with activities of daily living because of her mobility limitations.
There was insufficient information about the beneficiary’s problems with activities of daily living if she used a manual wheelchair.
The records provided did not include evaluations/follow-up visits related to the beneficiary’s respiratory or cardiac problems. It was unclear how those health issues affected her ability to use a manual
The beneficiary was 67 year old woman with a history of chronic venous stasis and chronic non-healing leg wound. She went to the Emergency Room (December 27, 2013) complaining of bilateral lower extremity swelling (cellulitis) and pain. She had a severe infection (septic shock), was admitted to the hospital, was seriously ill, and “ended-up with bilateral above-knee amputation.” She developed multiple problems, including kidney failure (required dialysis), and cardiac problems (atrial fibrillation). She had a history of total left hip replacement.
After her hospital stay she was transferred to a rehabilitation facility (January 27, 2014). Per a medical …show more content…
Date of service: January 03, 2015 (Delivered on April 3, 2014).
The services at issue are reasonable and necessary *
Reasonable yes,
Necessary: unknown if it was as beneficial as other services (manual wheelchair)
Do you agree or disagree with the QIC's conclusion regarding the medical necessity of the services at issue? *
Yes
Please justify your agreement or disagreement with the QIC's conclusion regarding the medical necessity of the services at issue (follow Optimal's writing guidelines) *
I AGREE with the QIC’s decision to deny payment for the power wheelchair. The information in the records submitted failed to support the beneficiary’s medical need for such equipment.
There was insufficient information about the beneficiary’s problems with activities of daily living because of her mobility limitations.
There was insufficient information about the beneficiary’s problems with activities of daily living if she used a manual wheelchair.
The records provided did not include evaluations/follow-up visits related to the beneficiary’s respiratory or cardiac problems. It was unclear how those health issues affected her ability to use a manual