[Noah930]

Here are 2 problems I came across, today:

1) I asked for authorization from an insurance company for bilateral carpal tunnel releases in a man with electrodiagnostically severe carpal tunnel syndrome. "Severe" being a key component of my disgust. When a diagnosis is "severe" and the signs and symptoms match the disease, the standard of care is to proceed onto surgery. And his symptoms and exam support the diagnosis of carpal tunnel syndrome. The request was denied (or, "non-certified" in insurance jargon) because the peer review physician was unable to make contact with myself of the other doctor involved in the patient's care regarding this issue. His denial letter listed a bunch of reasons why, but when one of the other docs with whom I work called him back later to ask him what was up with his decision, we were given the unofficial story that if no peer-review contact is made, a denial letter is automatically generated.

What about the detailed consult note or EMG report I included in my request? I guess that doesn't stand for anything if the insurance company decides it's not convenient for them.

According to the list of things I failed to address, apparently carpal tunnel release is not necessary (per whatever guidelines this utilization review doc was using) until the patient has failed at least a month of modified duty, splinting, and therapy, or signs on physical exam such as muscle wasting are present. What sense does it make to send a guy to therapy for a month or take him off of work for that amount of time just to prove the inevitable? Muscle atrophy before surgery is indicated? That's like saying we won't send out the firetrucks to your home until the flames are visible from at least 4 miles away.

2) Another request for carpal tunnel release. This time I got a call in the morning saying I had to call the peer review physician by 4 pm...Central time. Otherwise my request would be denied. So I called immediately. The guy was busy but called back 45 minutes later. He had already denied the surgery, and gave me several reasons why. He didn't want to hear anything I had to say for explanation of my request, so I couldn't even address his concerns. There was NO collegial exchange of information. But if I had any other documentation, I could fax it to him. No new documentation was allowed. I could only submit existing documentation for consideration. (Who made up that rule? In the past I've had other peer reviewers specifically tell me to write something up quickly and fax it to them to address their concerns so they could check off the boxes on some form to let them authorize the surgery requested.)

There certainly was no peer-to-peer discussion in the spirit of the regulation. Rather, I was handed my sentence, much like you're guilty until proven innocent when it comes to traffic court. Only I wasn't even allowed to plead my case. Just show up and have the judge tell you you're guilty.



In medicine there's a Golden Rule: He who has the gold, makes the rules. In this day and age, it's the insurance companies who make the rules.