Medical Necessity Research Articles

KNOWLEDGE REGARDING MODE OF DELIVERY IN PRIMARY GRAVIDA WOMEN

In Pakistan, childbirth knowledge among primary gravida women—those experiencing pregnancy for the first time—plays a crucial role in shaping their decisions regarding the mode of delivery. Misconceptions, cultural beliefs, and social pressures significantly influence these women’s preferences, often leading to an increased rate of elective caesarean sections (CS) without medical necessity. Understanding the knowledge level regarding delivery options in this population is essential to improve maternal and neonatal outcomes. Objective: This study aimed to assess the level of knowledge regarding the mode of delivery among primary gravida women attending antenatal care at Jinnah Hospital, Lahore, and to identify gaps that may influence their decision-making. Methods: A descriptive cross-sectional study design was employed, targeting 150 primary gravida women at Jinnah Hospital, Lahore. A purposive sampling technique was used, and data were collected using a structured questionnaire comprising demographic questions and items related to knowledge and perceptions of vaginal and caesarean deliveries. Data were analyzed using SPSS version 22, with descriptive statistics used to summarize findings. The questionnaire’s reliability was confirmed with a Cronbach’s Alpha of 0.986, and validity was established through the Kaiser-Meyer-Olkin (KMO) measure and Bartlett’s Test of Sphericity. Results: The findings indicated that 34.7% of participants had poor knowledge regarding the mode of delivery, 62.0% had moderate knowledge, and only 3.3% demonstrated good knowledge. Most participants preferred CS due to fear of labor pain and misconceptions about vaginal delivery risks. A majority (90%) of respondents viewed seeing the baby immediately after vaginal delivery positively, and 44% believed that the emotional relationship with the baby is enhanced following vaginal delivery. Informal sources, primarily relatives and friends, were the main sources of delivery-related information, contributing to persistent knowledge gaps and misconceptions. Conclusion: The study reveals significant knowledge gaps among primary gravida women regarding delivery options in Pakistan, with many women favoring CS due to fear and lack of accurate information. Structured antenatal education programs are necessary to address misconceptions and empower women to make informed decisions about their delivery mode. Improved education could reduce unnecessary CS rates and support healthier maternal and neonatal outcomes.

Cancer-Related Cognitive Impairment: A Survey of Speech-Language Pathologists' Knowledge, Training, and Attitudes

Purpose: This study examined speech-language pathologists' (SLPs') professional knowledge, training experiences, and attitudes in assessing and treating individuals with cancer-related cognitive impairments (CRCIs). Understanding these concepts is necessary for evaluating SLPs' role in supporting individuals with CRCIs. Method: A web-based survey was completed by 147 SLPs over a 2-month period. The survey explored their professional knowledge, training, and attitudes regarding CRCI assessment and intervention. Results: Three quarters of participants reported some experience with individuals with CRCIs. Most participants reported that providing care for individuals with CRCIs was within the SLP scope of practice (97%) and an ethical responsibility (93%). Approximately 65% of participants completed some form of training for providing services for this population; 98% would pursue diagnostic training in the future, and 66% would pursue intervention training in the future. Regarding attitudes, 80% of participants shared that they were comfortable with the idea of providing cognitive-communication services to individuals with CRCIs, and almost all (97%) felt that cognitive-communication services were a medical necessity for this population. Additional analyses were conducted to assess the effect of years of experience on various aspects of professional knowledge and attitudes. Conclusions: SLPs were trained to assess and treat the cognitive-communication domains impacted by CRCIs. Recommendations for meeting this need are also discussed. Further research regarding the role of SLPs in the assessment and treatment of CRCIs is warranted.

Neuroschistosomiasis in Young Filipino Patient Presenting with Seizure.

Diagnostic challenge and insightThis case highlights the importance of considering a broad differential diagnosis in patients with atypical neurological presentations, particularly in those from regions where parasitic infections are endemic. The internist plays a crucial role in integrating clinical, serological, and imaging data to arrive at a correct diagnosis, in this case, neuroschistosomiasis.Tailored treatment strategyThe case illustrates the value of personalized patient care. Initiating empirical treatment based on a combination of clinical suspicion, high-risk patient demographics, and imaging findings, without invasive procedures, demonstrates the internist's role in managing complex cases where patient preferences must be balanced with medical necessity.

Poisoning with Local Anesthetics Following Circumcision : A Case Report

Introduction: Circumcision or posthectomy is the removal of the foreskin, this act seems commonplace practiced by paramedical personnel or unqualified traditional practitioners who may cause significant complications. Objective: Our work aimed to highlight one of the complications of this act which must remain a supervised medical act. Observation: We report the case of a 2-month-old infant who presented with complications related to anesthesia. the clinic was dominated by convulsions and alteration of the state of consciousness 15 minutes after circumcision in this well infant carrying without any particular history. The evolution was favorable thanks to support rapid and urgent about 20 minutes with the cessation of convulsions and a return to consciousness, the patient was monitored for 48 hours then return home was indicated due to the absence other complications. Conclusion: Circumcision is a widespread act throughout the world either by medical necessity or by religious tradition. its trivialization and its practice by non-experts, explains the multiple complications observed.

Living Dead: Trans Cooperations with Mad Necropolitics and the Mad Trans Coalitions that Might Replace Them.

Trans subjectivities continue to be included in major compendia of mental illness, despite recent moves to depathologize "cross-gender identification." Regardless, the inclusion of "gender dysphoria" is often framed as a formal mechanism to support access to gender affirming care as transgender subjectivities are re-conceptualized as part of sex/gender diversity and away from madness. The latter permits trans individuals to evade sanist oppressions. However, moves to disassociate from mad individuals also often serve to condone sanism. For instance, a contemporary policy landscape often sees transgender advocates arguing for the "medical necessity" of gender affirming care for gender dysphoria as a "recognized medical condition," thereby skirting the inclusion of gender dysphoria as a psychiatric condition and implying that gender dysphoria carries a special ontological status that separates it from madness (reified as "mental illness"). More though, this framework endorses material violences toward mad individuals that are often advanced via the workings of the state to consign marginalized constituents to death by withholding the means of life, i.e., necropolitics. In the following, I argue that trans disassociations from madness often endorses or assents to mad necropolitics. Drawing from Mbembe's (Necropolitics. Duke University Press, Durham, 2019) framework, I suggest that medicalizing trans narratives, despite being used to object to anti-trans laws in contemporary context, ideologically support mad "death worlds" organized through the U.S.A. welfare state and prison industrial complex. However, I also suggest alternative strategies, i.e., intersectional collaboration, that may uplift mad and/or trans communities.

Pay for a free service, access to cesarean section in the slums of Dakar

BackgroundIn sub-Saharan Africa, equitable access to cesarean section remains a major challenge for reducing maternal and neonatal mortality, particularly among disadvantaged populations. This situation is further exacerbated in slums, where women face significant financial barriers to accessing expensive healthcare services, such as cesarean. Within this context, this paper aims to study access to emergency cesarean services among women living in the slums of Dakar, considering the free cesarean policy implemented in Senegal since 2005.MethodQuantitative data were collected using a cross-sectional retrospective approach, from 18 health facility managers and 260 women living in slums in Dakar who had undergone cesarean delivery between July and December 2022. The surveys aimed to collect socio-demographic data on women and the costs they paid to have a cesarean section, as well as on the application of the policy of free caesarean sections by public health facilities. The data were processed using Stata.ResultsThe results indicated that poor women residing in Dakar slums do have access to emergency cesarean section services in public health facilities. However, a significant portion of these women come from impoverished households and lack higher education, making them more vulnerable to financial constraints when seeking a C-section. Despite cesarean sections being performed primarily based on medical necessity, regardless of the woman's economic status, ethnicity, or educational background, women often find themselves having to pay substantial amounts to undergo the procedure. This is particularly concerning, as cesarean sections are intended to be entirely free in public health facilities in Senegal. Health facility managers attribute this financial burden to the State, which recurrently delays reimbursements for cesarean sections, forcing them to charge women higher prices for the procedure.ConclusionA more rigorous enforcement of the policy for free cesarean section could greatly enhance access to this obstetric practice for women living in the slums of Dakar.

Induction of Labor: A Narrative Review on Cost Efficiency in Maternity Care.

The clinical and financial implications of induction of labor (IOL) in comparison to elective cesarean sections and expectant management are examined in this review. IOL is frequently used to avoid complications such as hypertensive disorders and stillbirth, but is can be expensive, particularly if a failed induction is followed by a cesarean. The cost-effectiveness of IOL varies based on factors such as gestational age, maternal obesity, and prior cesareans. Misoprostol has proven to be a more cost-effective induction method than oxytocin, with higher success rates for vaginal delivery and shorter hospital stays. However, spontaneous labor remains the most cost-efficient option, requiring fewer interventions and reducing costs. Membrane sweeping is one alternative that reduces costs and promotes unplanned labor. Although high-risk situations may necessitate elective IOL, routine use of these devices without a medical necessity raises expenditures without enhancing outcomes. It is recommended that healthcare professionals implement careful labor management techniques, utilizing cost-effective approaches whenever feasible, particularly in resource-limited settings. More randomized trials are required to evaluate the long-term effects of IOL on costs and health, thus shaping future labor management strategies.

“Where’s my baby?” A feminist phenomenological study of women experiencing preventable separation from their baby at caesarean birth

ProblemSeparating women and babies immediately after birth contributes to poor birth experience and reduced satisfaction. BackgroundA negative birth experience can impact a woman’s transition to motherhood and emotional well-being beyond the newborn period. Separating women from their baby at birth is known to reduce birth satisfaction and is more likely to happen at caesarean section births. QuestionWhat is the experience of women who are separated from their baby after caesarean section birth without medical necessity? MethodsUnstructured, in-depth phenomenological interviews were conducted with fifteen women who had been separated from their well-baby at caesarean section birth. Data was analysed using a Modified van Kaam approach. A novel feminist phenomenological framework with two birthing theories was used to explore the experience of the participants. FindingsFour major themes emerged – Disconnection, Emotional Turmoil, Influence, and Insight. These demonstrated significant trauma that both the separation and perinatal care created. DiscussionThe participants recognised their vulnerability and the lack of power and control they had over themselves and their baby, which was seemingly not acknowledged. Provider and hospital needs were valued above those of the women. ConclusionWoman-centred care was not evident in the treatment of these women despite the attendance of a midwife at each birth. This research challenges midwives and other health care providers to support and advocate for those birthing by caesarean section to return power and control and support them to remain in close physical contact with their baby immediately after birth.

Against the Grain: Consumer’s Purchase Habits and Satisfaction with Gluten-Free Product Offerings in European Food Retail

Across the world and within Europe, a growing number of consumers are choosing to buy gluten-free products. Motivations for a gluten-free diet and the consequences of consuming gluten are varied, from a medical necessity for those diagnosed with celiac disease to a range of health complications and discomfort for those who are gluten-intolerant. In this research, 7296 gluten-free consumers across 13 European countries responded to an online survey on the 33 types of gluten-free products purchased, how frequently they purchased them, their satisfaction with gluten-free quality and availability, the problems they have experienced, and the strategies they have employed to cope with these problems. The investigation examines whether and how these consumer attitudes and behaviors differ between those diagnosed with celiac disease, those who are gluten-intolerant, and those who are caregivers for others with a gluten-free diet. The results show that significant differences existed for all these habits and issues across the three gluten-free consumer groups. Specifically, caregivers purchased most of the gluten-free product types more frequently than the other two groups, experienced more availability problems, and were more likely to shop at multiple stores or make their own gluten-free products. Celiac-diagnosed consumers tended to buy gluten-free products more frequently than those who are gluten-intolerant, and they tended to be the most satisfied with the quality and range of gluten-free offerings. Despite purchasing frequency differences between the groups, the results suggest a similar hierarchy of gluten-free products that could provide the foundation for a European gluten-free food basket.

Fentanyl, Heroin, Methamphetamine, and Cocaine Analyte Concentrations in Urine Drug Testing Specimens

The US is experiencing a protracted drug overdose crisis primarily associated with exposure to illicitly manufactured fentanyl (IMF), methamphetamine, and cocaine. Overdose risk and treatment responses may be directly affected by absolute drug exposure concentrations and drug use prevalence. To quantify changes in absolute drug exposure concentrations from 2013 to 2023. This cross-sectional study analyzed urine drug testing (UDT) results from urine specimens collected between January 1, 2013, and August 22, 2023, in 49 states and the District of Columbia. Urine specimens were obtained from patients aged 18 years or older who presented to substance use disorder treatment clinics. The UDT was ordered by clinicians based on medical necessity. Urine specimens were analyzed for the following drugs or metabolites (analytes tested in parentheses): fentanyl (fentanyl), heroin (6-monoacetylmorphine), cocaine (benzoylecgonine), and methamphetamine (methamphetamine) using liquid chromatography with tandem mass spectrometry. Relative concentrations of fentanyl, heroin, cocaine, and methamphetamine. Creatinine-normalized drug concentration values were log-transformed prior to visualization and statistical analyses. The Mann-Kendall trend test was performed to examine trends over time. To estimate the geospatial and temporal patterns of drug concentration, a second series of models (1 for each drug) with an interaction effect for clinic location and collection year were fit. A total of 921 931 unique UDT samples were collected from patients (549 042 males [59.6%]; median [IQR] age, 34 [27-44] years). The adjusted fentanyl concentration in urine specimens was 38.23 (95% CI, 35.93-40.67) ng/mg creatinine in 2023 and 4.61 (95% CI, 3.59-5.91) ng/mg creatinine in 2013. The adjusted methamphetamine concentration was 3461.59 (95% CI, 3271.88-3662.30) ng/mg creatinine in 2023 and 665.27 (95% CI, 608.51-727.32) ng/mg creatinine in 2013. The adjusted cocaine concentration was 1122.23 (95% CI, 1032.41-1219.87) ng/mg creatinine in 2023 and 559.71 (95% CI, 524.69-597.06) ng/mg creatinine in 2013. The adjusted heroin concentration was 58.36 (95% CI, 48.26-70.58) ng/mg creatinine in 2023 and 146.59 (95% CI, 136.06-157.92) ng/mg creatinine in 2013. Drug concentrations varied across US Census divisions. This cross-sectional study found that absolute concentrations of fentanyl, methamphetamine, and cocaine in urine specimens increased from 2013 to 2023, with a decrease in heroin concentration during that period. The findings suggest that exposure to these substances, as well as the illicit drug supply, has fundamentally changed in many parts of the US, highlighting the need to reinforce surveillance initiatives and accelerate efforts to treat individuals with IMF and/or stimulant exposure.

A review of Peyronie's disease insurance coverage.

Peyronie's disease (PD) is a fibroproliferative disorder that causes an abnormal curve of the penis resulting in pain, discomfort, and erectile dysfunction with management options including correctional surgery, penile external/internal devices, shock wave therapy (SWT), intralesional Verapamil (IV), and collagenase Clostridium histolyticum injections. To investigate the insurance coverage of these treatment options. The authors performed a cross-sectional analysis of the top US insurance policies for coverage of PD. Companies were chosen based on their market share and enrollment. Their policies were identified through a Web-based search and telephone interviews, and the companies' medical necessity criteria were defined. The online policies were then re-examined for interval change 3 years later. There are significant discrepancies for in coverage for the different modalities of Peyronie's treatment. Of the 100 companies examined, only 54% of companies had a policy that directly addressed the treatment coverage for PD. The most covered treatment was CCH injections with 37 companies providing unanimous coverage (n = 37, 100%). Within this category, all companies required a palpable plaque as a requirement. Additionally, external/internal devices were unanimous covered by 18 companies (n = 18, 100%). Surgical treatment was covered by eight companies with six companies denying coverage (n = 8 vs. n = 6, 57.1% vs. 42.9%). IV was covered by two companies. The least covered treatment option was SWT which was universally denied by 19 companies (n = 19, 100%). Insurance coverage of PD should be aligned with current medical literature to better increase access to care. This study is limited by the updated policies of insurance companies and future applicability. Additionally, this study assumes that a written policy will provide coverage and may overestimate the actual extent of coverage. Finally, this study only addressed some of the common treatment options of PD and did not expand on all possible treatment options. Differing rates for modalities of treatment may present a barrier for patients to receive individualized and adequate treatment for PD.

Ethics of Organ Donation and Transplantation: Toward Self-Sufficiency.

Organ donation, intersecting medical necessity and ethical responsibility, calls for policies respecting individual autonomy while aiming for societal selfsufficiency. This article evaluates various government policies, emphasizing the ethical use of nudges in decision-making and the potential impact on autonomy. We argue that, while some policies might be coercive, others may inadvertently disrespect autonomy through subtle influences on decisionmaking. To reach self sufficiency in organ donation and transplantation and to keep adherent to medical ethics, especially informed consent, and gift of life campaigns, governments must determine the legal procedures by which their residents are registered, or can register, as organ donors. Provided that governments recognize that people have a right to determine what happens to their organs after they die, there are 4 feasible options to choose from: optin, opt-out, mandated active choice, and voluntary active choice. This article investigated the ethics of these policies' use of nudges and pokes to affect organ donor registration ways, rules, and rates. We argue that the use of nudges in this context is morally problematic. It is disrespectful of people's autonomy to take advantage of their cognitive biases since doing so involves bypassing, not engaging, their rational capacities. We conclude that, although mandated active choice policies are not problem free, they are coercive; after all, voluntary active choice, opt-in, and opt-out policies are potentially less respectful of people's autonomy since their use of nudges could significantly affect people's decision making.

Racial and ethnic disparities in prior authorizations for patients with cancer.

Prior authorization is used to ensure providers treat patients with medically accepted treatments. Our objective was to evaluate prior authorization decisions in cancer care by race/ethnicity for commercially insuredpatients. Retrospective study of 18,041 patients diagnosed with cancer between January 1, 2017, andApril1,2020. Using commercial longitudinal data from a large national insurer, we described the racial and ethnic composition in terms of prior authorization process outcomes for individuals diagnosed with cancer. We then used linear regression models to evaluate whether disparities by race or ethnicity emerged in prior authorization process outcomes. The self-identified composition of the sample was 85% White, 3% Asian, 10% Black, and 1% Hispanic; 64% were female, and the mean age was 53 years. The average prior authorization denial rate was 10%, and the denial rate specifically due to no medical necessity was 5%. Hispanic patients had the highest prior authorization denial rate (12%), and Black patients had the lowest prior authorization denial rate (8%). Regressions results did not identify racial or ethnic disparities in prior authorization outcomes for Black and Hispanic patients compared with White patients. We observed that Asian patients had lower rates of prior authorization denials compared with White patients. We observed no differences in the prior authorization process for Black and Hispanic patients with cancer and higher rates of prior authorization approvals for Asian patients compared with White patients.

Meeting the Needs of People With Severe Quadriplegia in the 21st Century: The Case for Implanted Brain–Computer Interfaces

Background In recent decades, there has been a widespread adoption of digital devices among the non-disabled population. The pervasive integration of digital devices has revolutionized how the majority of the population manages daily activities. Most of us now depend on digital platforms and services to conduct activities across the domains of communication, finance, healthcare, and work. However, a clear disparity exists for people who live with severe quadriplegia, who largely lack access to tools that would enable them to perform daily tasks digitally and communicate effectively with their environment. Objectives The purpose of this piece is to (i) highlight the unmet needs of people with severe quadriplegia (including cases for medical necessity and perspectives from the community), (ii) present the current landscape of assistive technology for people with severe quadriplegia, (iii) make the case for implantable BCIs (how they address needs and why they are a good solution relative to other assistive technologies), and (iv) present future directions. Results There are technologies that are currently available to this population, but these technologies are certainly not usable with the same level of ease, efficiency, or autonomy as what has been designed for the non-disabled community. This hinders the ability of people with severe quadriplegia to achieve digital autonomy, perpetuating social isolation and limiting the expression of needs, opinions, and preferences. Conclusion Most importantly, the gap in digital equality fundamentally undermines the basic human rights of people with severe quadriplegia.

Routine preoperative assessment for cataract surgery is a source of frustration for primary care providers

BackgroundCataract surgery is one of the most common surgical procedures performed in older adults in the United States and is generally considered to be extremely low-risk. As of 2019, routine preoperative evaluation within 30 days of surgery is no longer mandated by the United States of America (USA) Centers for Medicare & Medicaid Services (CMS) for ambulatory surgery centers, but it is unclear how primary care providers perceive this change.MethodsWe performed a qualitative analysis of semi-structured interviews with six primary care providers to explore primary care providers’ perspectives on routine preoperative assessment for cataract surgery.ResultsPrimary care providers commented on the large number of referrals they receive for preoperative assessment before cataract procedures. The analysis revealed an overarching sentiment of resentment over the time, effort, and resources expended on these assessments. Themes included the lack of awareness of the updated regulations that no longer require a history and physical to be completed within 30 days and the perception of a universal lack of medical necessity to perform preoperative assessment for cataract surgery. Providers also commented on the strain on limited resources and the burden on patients. The relationship between specialties and professional roles emerged as another important theme.ConclusionsReferrals for preoperative clearance for cataract surgery continue to burden providers, patients, and the health system, and represent an opportunity to streamline care in this patient population.

A Cross-Sectional Analysis of American Insurance Coverage of Upper and Lower Lid Blepharoplasty.

Dermatochalasis is a common condition that can cause obstruction of peripheral visual fields and impairment of daily activities. These effects can be addressed with a blepharoplasty, which may be considered a cosmetic procedure by American health insurers. The authors assessed insurance coverage of all indications of blepharoplasty and their medical necessity criteria. A cross-sectional analysis was conducted of 70 insurance policies for blepharoplasty. The insurance companies were selected based on their state enrollment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were extracted from the publicly available policies. Of the 70 insurance policies assessed, 67 (96%) provide coverage for blepharoplasty. There were 7 indications for coverage, the most common being dermatochalasis causing functional visual impairment (n = 56, 80%), prosthesis difficulties in an anophthalmic socket (n = 44, 63%), and congenital ptosis (n = 38, 54%). Of companies that indicated coverage for dermatochalasis, 95% required visual field loss testing to qualify for coverage. Significantly more companies required a 30% loss in the superior visual field for coverage versus the literature-recommended amount of 24% loss (n = 14 versus n = 3, 26% versus 6%, P = 0.0067). There is a great discrepancy in insurance policy criteria for coverage of blepharoplasty, especially regarding requirements for visual field testing. Unfortunately, this disparity does not reflect the current literature as to whom may gain significant functional benefit from blepharoplasty.

Association between mode of delivery and early neurodevelopment: A prospective birth cohort study.

This study suggested that the adverse impact of CD on child neurodevelopment stems from the procedure itself rather than CD-related medical conditions. It is important to minimize the use of CD when there is no medical necessity. • Caesarean delivery (CD) may influence child neurodevelopment and other long-term outcomes. • In China, approximately one-quarter of CD are performed due to maternal request without medical indications. • The negative impact of CD on the neurodevelopmental outcomes of children may be primarily attributed to the procedure itself, as opposed to related medical conditions. • In the absence of medical indications, unnecessary CD may have adverse impacts on children's neurodevelopment.

Outcomes Following Paediatric Tonsillectomy From a UK Tertiary Centre: Imperial College Healthcare NHS Trust's Experience During the COVID-19 Pandemic.

Background Paediatric tonsillectomy ranks among the most frequently performed surgical procedures globally. The substantial volume of these operations underscores their considerable impact on healthcare systems and resource allocation. Recent guidelines in the United Kingdom have emphasized the safety and feasibility of performing tonsillectomies as day-case surgeries. The interplay of medical necessity, high incidence, and evolving guidelines underscores the importance of continually evaluating and optimizing tonsillectomy practices. This study assesses the outcomes of paediatric tonsillectomies at a UK tertiary centre during the COVID-19 pandemic and the implementation of day-case guidelines. Methodology A retrospective analysis was conducted on patients under 18 years of age who underwent tonsillectomy between April 2021 and September 2022. Data on postoperative events until discharge and re-attendance within 14 days were recorded. High-risk subgroups were analysed: subgroup A (two years of age and weighing 12-15 kg), and subgroup B (severe obstructive sleep apnoea (OSA) on polysomnography defined as an apnoea/hypopnoea index >30 events per hour). Binary logistic regression assessed whether age, weight, sex, or procedure time predicted extended hospital stay (more than one night) or the need for oxygen. Day-case tonsillectomy guidelines were created after multi-disciplinary team approval. Results A total of 117 patients underwent tonsillectomy, with a median age of four (n = 72 male). OSA/sleep-disordered breathing accounted for 88% (n = 103), and 68% (n = 70) underwent a preoperative sleep study. Same-day discharge rate was 26% (n = 31). Postoperatively, 86 patients were admitted; 44 required overnight oxygen saturation monitoring, 35 for weight extremes, and seven for poor oral intake. Of those admitted, 70 (81%) patients remained well overnight, and 76 (88%) patients were discharged the next day. In subgroup A (n = 17), the average weight was 13.4 kg; two had transient desaturations. Fourteen were discharged the next day. In subgroup B (n = 34), four had transient desaturations with a further two requiring oxygen. Weight (p = 0.071) within the 'extended hospital stay model' and procedure time (p = 0.052) within the 'need for oxygen' model approached significance for predicting outcomes. Conclusions This study offers early insights into paediatric tonsillectomy outcomes during the COVID-19 pandemic at a tertiary centre. Although the same-day discharge rate was lower than the national average, most patients, including high-risk groups, remained clinically stable and were discharged within 24 hours.

An Overview of the Challenging Process of Prior Authorization: Medical Necessity for a Better Way

An Overview of the Challenging Process of Prior Authorization: Medical Necessity for a Better Way

The Literature that Commercial Insurance Payers Use to Substantiate Knee Osteochondral Allograft Policies Are of a Low Level of Evidence.

The purpose of this study is to analyze how the largest insurance companies support their medical necessity policies regarding osteochondral allograft transplantation (OCA) and to determine whether the literature they cite in their policies is of a high level of evidence (LOE). The 10 largest national health insurance companies were identified. Each payer was contacted via phone or email to obtain their coverage policy regarding OCA. For each policy, the medical necessity criteria were recorded, and all cited references were screened. For all references applicable to OCA, the LOE was recorded, and each reference was screened to determine whether they mentioned the specific criteria reported in the policies. The medical policies for 6 of the 10 national health insurance companies were identified. These 6 policies cited a collective total of 102 applicable references. Most of these studies were an LOE of IV (n = 58, 56.9%) and an LOE of V (n = 18, 17.6%). There were similarities amongst the medical necessity criteria between different commercial payers; however, most criteria were poorly supported by the cited literature. Our results demonstrate that commercial insurance companies utilize studies that are of a low LOE when justifying their medical necessity criteria. Moreover, these cited studies infrequently support or mention the commercial payers' criteria. Future studies should continue to explore how well-supported insurance policies are with the goal of potentially increasing access and authorization for well-supported treatment modalities.