The Power of a Peer-to-Peer: Identifying an Unrecognized Clinical Condition
Sometimes a request for care—no matter how well-intentioned—is denied during the prior authorization process. When this happens, providers can learn more about the decision, and in certain circumstances have it reevaluated, by speaking with an EviCore clinician.
While these peer-to-peer consultations often initially focus on gaps in the supporting documentation, they also generate discussion that can help improve a patient's care. In one recent instance, a consultation led to a new, more urgent diagnosis—and immediate approval for emergency surgery.
Asking the Right Questions
Lower back pain crops up for most people at some point: National statistics say about 80% of adults experience it. So when a 43-year-old woman came in complaining of lower-back and leg pain, the physician assistant (PA) who treated her didn't see much out of the ordinary. The provider diagnosed her with radiculopathy caused by a herniated disc and requested a laminotomy to relieve the pressure.
The established evidence, however, says back pain often responds to conservative treatment, such as physical therapy. Before surgery is considered appropriate, medical guidelines require that a patient undergo 6 weeks of conservative care and receive an X-ray, neither of which had been done in this case. What's more, the patient suffered from severe obesity, putting her at high risk of complications and mortality during surgery. The request was denied.
Dr. Richard Zipnick, an associate medical director with EviCore, was tapped for the peer-to-peer. A board-certified, fellowship-trained orthopedist, Dr. Zipnick has treated patients for about 25 years. “I practice spine surgery. I am seeing patients in my office, so I know what to ask," he says.
During the conversation, he wanted to know if the patient had any problems with bowel and bladder function. The PA said yes. “I said, ‘That's cauda equina syndrome,’ and a red light went on in the physician assistant's mind: This patient needs surgery now."
A New Diagnosis
As they exit the spinal cord, the nerves that connect to the legs, bowels, bladder, and genitals resemble a horse's tail, or cauda equina in Latin. Compression of these nerves causes cauda equina syndrome, or CES, which is recognized by “red flag" symptoms that include severe lower back pain, weakness, numbness, and problems with bladder and bowel control.
“It turned out this patient's disc herniation was so large it was compressing the nerves to the bowel and bladder," Dr. Zipnick says.
He suspects the patient's weight may have obscured her diagnosis. Obesity puts patients at risk for lower back pain. The woman's condition, it turned out, had nothing to do with obesity.
Immediate Approval
To relieve the compression, patients need surgery—urgently. Studies show that procedures performed 1-2 days after onset are more effective at reducing symptoms and have lower complication and mortality rates. If not adequately addressed, CES can leave patients with debilitating pain, incontinence, and other problems.
In this case, the PA originally requested elective surgery, which could have required the patient to wait for weeks or months. But with the CES diagnosis in hand, the PA received immediate approval for an emergency laminotomy.
“By offering what was essentially a second opinion, I was able to rapidly facilitate the patient's care," Dr. Zipnick says. “That would not have happened without peer-to-peer."