What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

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Documenting Test Results the Ed and Midge Way

I have a ten-year-old Yorkie named Ed. Ed is experienced and knows the daily routine of our house. Last year, we got a Yorkie puppy named Midge. She initially knew nothing.  It has been entertaining to watch Ed educate Midge on what to do. Midge watches Ed closely and then does whatever Ed does. She is a true Ed Mini-Me. If Ed lays down, Midge lays down.  If Ed asks to go out, Midge wants to go out, too. If Ed begs for a treat, so does Midge.

Since Ed is a pretty good dog, most of what he has taught Midge have been good things, like ask to go outside when you need to potty and sit to say “please” when you want a treat.  But Ed also has some bad habits that he has imparted to Midge.  Ed still has the Yorkie propensity to yap at the door when the doorbell rings, and so Midge has also learned to also sound the alarm.

Medical education is like this. I remember being a young dog medical intern and watching my heroes, the senior residents. Not everything in medicine is taught in medical textbooks and didactic lectures!  Much of what we actually learn as medical practitioners is an imitation of our elders.  For example, I watched what the senior residents ate (junk), when they slept (rarely) and how they treated nurses (some good, some poorly), among other things. Like Ed, most of what my senior residents taught me by example was good. But there are a few sketchy practices handed down from medical resident to medical student that can become bad habits.

Ed: Do what I do. Midge: Ok!
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Using a Wrench Instead of a Hammer for Alcohol Withdrawal

I am seeing a 52-year-old male in my jail medical clinic who was booked yesterday on a felony DUI charge.  He says he drinks “a lot of beer” but denies having a drinking problem.  He is cranky and not really cooperative.  He does not want to be here.  However, the deputies tell me that he did not sleep much last night and did not eat breakfast.  I note that he has a mild hand tremor and a heart rate of 108.  According to the clinical Institute Withdrawal Assessment for Alcohol–revised version (the most common tool used in the United States to assess the severity of alcohol withdrawal since 1989) my patient needs no treatment for alcohol withdrawal.  But this is wrong!  In actuality, my patient is experiencing moderate withdrawal and should be treated immediately and aggressively. 

 Using CIWA is like using a wrench to pound in a nail.  It can be done, but it is not really efficient or accurate.  A different tool (a hammer) could drive the nail much more quickly and effectively. CIWA is simply not the right tool to assess alcohol withdrawal.  We should be using something better.

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Gabapentin for Musculoskeletal Pain?

At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin.  One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding.  He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever.  The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago.  The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).

Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections.  These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics).  Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives. 

The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.

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Reducing NSAID Use PLUS NSAID Prescribing Guideline

Through many years of experience in correctional medicine, I occasionally have come up with a speech or dialogue that works especially well with patients; a speech which I then use over and over again. One of these speeches is one I use to get patients to take fewer NSAIDs.

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When Should Medical Clearance Be Done? PLUS Sample Guideline!

When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.

One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. “This guy’s an a**hole,” the officer says. “He won’t do anything I ask. He just ignores me.” He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, “That’s because he’s dead!”

Medical clearances are a hugely important and often neglected part of the jail medical process.

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Constipation Plus Sample Guideline

Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).

I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject.  We all received “The Talk” (about sex and reproductive health) when we were adolescents.  But nobody seems to talk about how to have a proper bowel movement.  It is a subject that inevitably causes giggling and uncomfortable laughter.  It is not spoken of in polite society.  As a result, many people do not understand how their bowels work.  I have found this to be a big problem in the jails I work in.  Inmates complain of constipation when they are not really constipated.  They are bowel-fixated when there is no reason for them to be.  Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.

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Skeletal Muscle Relaxant Guideline

Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.

Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”

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Reader Question: Don’t Be the Decider

I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR

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How to Write an ATP (Alternative Treatment Plan)

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Many of us in supervisory positions in correctional medicine have Utilization Management (UM) duties. One common duty is to review requests from primary care practitioners for patient care procedures like a referral or, say, an MRI. We must then decide whether to approve the request or write an Alternative Treatment Plan (ATP). This process is loosely based on a similar practice done in HMOs in free world medicine, but there are important differences. In an HMO, the evaluator is deciding whether the HMO will pay for the procedure. If the requested procedure does not meet HMO criteria, the evaluator will deny the request. The procedure can still be done, but the patient and her physician will have to find an alternative method of paying for it. Also, the HMO evaluator does not offer opinions on whether the procedure is appropriate nor does she offer suggestions as to what could or should be done instead.

Correctional Medicine UM is different. Those of us doing these evaluations are not being asked about payment; we are being asked for permission to do the procedure at all. We cannot simply deny the request like an HMO can. If we do not think the procedure should be done, then we must say what should be done instead: The Alternative Treatment Plan.

When done poorly, the ATP can irritate the primary care practitioner and even create an adversarial relationship between the practitioner at the site and the UM evaluator. When done well, the ATP is a written conversation between two equal colleagues and the ATP process can actually improve patient care.

Doing it wrong

Like any other bit of writing, it is important at the outset to define who your audience is. The ATP should be written with three potential readers in mind. The first is the site practitioner who made the initial request. A bad ATP will leave the PCP feeling underappreciated, threatened and disrespected: “I don’t trust you and you are stupid.” A good ATP will leave the PCP feeling like you are on the same team and that you have their back: “You’re doing great! Let me help you.”

The second potential reader of the ATP is The Adversary, like a plaintiff’s lawyer or an advocacy group. A bad ATP will indicate that you are denying the patient reasonable and necessary medical services. A good ATP will show that nothing was denied and will not imply that any medical service is off limits.

ATPs are also read by nurses, who have to transcribe and record the ATP in the official record. A good ATP will make their life easier. A bad ATP can result in many hours of needless, morale crushing busy work.

In my experience, it does not take much more time to write a good ATP instead of a crappy one.  Most UM evaluators, however, have never been taught how to write and ATP.  Here is how I write mine:

Step one: Restate what is being requested.

The first sentence of the ATP should briefly summarize the case and re-state what is being requested.

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen.

Step two. Support your ATP.

The next section of the ATP contains the evidence that supports your ATP. This evidence can be pertinent positives, like x-rays, labs, previous visits. This evidence can also be pertinent negatives, like incomplete exams or missing data. Finally, this paragraph can also include pertinent research that supports your ATP, such as a quote from Uptodate, RubiconMD or InterQual.

  • The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report.
  • There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in most cases of hematuria.

Step 3. The ATP should defer the request; not deny it.

It is important to never (or rarely) use the word “denied.” Instead, you should restate what was requested and then say it is “deferred “pending whatever you want done instead, such as “Pending receipt of missing information,” “Pending complete evaluation of the patient at the site,” or “Pending case evaluation in a case review conference”

  • Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site.
  • Abdominal CT is deferred pending complete evaluation of the patient at the scene.

Step four. Tell the Primary Care Practitioner what you want them to do instead.

The next sentence contains instructions to the site practitioner.  This is the “ATP” and should be labelled as such.  I also always date the ATP.

  • 3/11/2019 ATP: The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results.
  • 3/11/2019 ATP: The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).

Step five. State that whatever was requested can be reconsidered later.

I always add this last sentence as well, to reaffirm that I am not denying any medical care. “The request from the first paragraph” can be considered thereafter, if clinically appropriate or anytime if medically necessary.

  • Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate.
  • CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary.

Step six: Contact the PCP to let her know that her request was ATP’d.

I don’t think that PCPs should find out from a UM nurse that their request was ATP’d. They will feel much better about the process if you contact them. This also opens a method of communicating about the case if they have more questions. This can be accomplished with a simple email:

  • Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Putting it all together, here are the full ATPs:

  • 56 yo male s/p colonoscopy done for guaiac positive stool. Request is for a routine post procedure FU with the gastroenterologist. The colonoscopy was negative except for a single sigmoid polyp. The pathology report on the sigmoid polyp is not attached to the report. 3/11/2019 ATP: Routine post-procedure FU with GI is deferred, pending complete evaluation of the patient and colonoscopy findings at the site. The site practitioner should obtain the pathology report on the sigmoid polyps and call me to discuss the case. The timing of follow colonoscopy will depend on the biopsy results. Off-site GI visit can be considered thereafter, as clinically indicated–or at any time if appropriate. Email to PCP: Hi Dr. X! Before we send this patient off-site to see the gastroenterologist, we need the biopsy report. If the adenoma is low risk, you can deliver the good news to the patient and tell him when his next colonoscopy will be scheduled. You’ll be seeing him in chronic care clinic in the meantime.
  • 63 yo male with reported gross hematuria.  Request is for CT of the abdomen. There is little clinical information accompanying the request.  I do not know if the patient has other medical problems, findings on physical exam, what medications he is one or what labs have been done.  Review of published treatment algorithms for the diagnostic work up of hematuria (Essential Evidence, Uptodate) show that CT is not the first diagnostic procedure that should be considered in almost all cases of hematuria. 3/11/2019 ATP: Abdominal CT is deferred pending complete evaluation of the patient at the scene.  The primary care practitioner should do a complete physical examination, appropriate labs and then discuss the case with me as to the next appropriate diagnostic procedure (ultrasound, cystography, etc).  CT can be considered thereafter, if clinically appropriate, or anytime if medically necessary. Email to PCP: Hi Dr. Y!  I am attaching an algorithm for work up of hematuria.  As you can see, there are several things that should be done before we consider a CT.  Will you please call me to discuss this case?

Two more examples (minus email):

53 yo s/p treatment for tongue cancer in remission. Request is for routine FU with ENT at six months from last visit.
The patient has finished all of his radiation sessions. ENT note from 7/17 states that the patient is in remission and that the six-month FU visit is “prn.” The consult request notes no new symptoms.
3/11/2019 ATP: ENT consultation deferred. Per last visit with ENT, further visits are to be “prn.” The site PCP should evaluate the patient at 6 months from the last visit and again at one year from the last visit. Off-site visit with ENT can be considered thereafter, as needed–or anytime if clinically necessary.

62 yo who had a liver ultrasound as part of Hepatitis C staging. The ultrasound showed a hypoechogenic polyp or cyst at the neck of the gall bladder. The radiologist says “A CT may be of value.” There is no report that the patient is symptomatic. I submitted the case to a RubiconMD radiologist, who thinks this is an incidental finding and repeat ultrasound in 6 months is a better methodology to follow this incidental finding.
3/11/2019 ATP: Abdominal CT is deferred. Per RubiconMD radiologist’s recommendation, the site PCP should order a follow up ultrasound at ~6 months. CT may be considered thereafter as clinically appropriate (or anytime if necessary).

As always, what I have written here is my opinion based on my training, experience and research.  I could be wrong! If you disagree, please say why in comments.

A previous version of this article was published in CorrDocs, the Journal of the American College of Correctional Physicians

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