Standard of Care

A 50 year-old woman, four weeks post hysterectomy and on chronic hormone replacement therapy, presented to an internist's office with pleuritic chest pain, shortness of breath and fatigue. She was not in great distress and the O2 Saturation was normal. However, the D-Dimer test (a nonspecific, but suggestive test for the presence of blood clots) was positive. The physician felt it was critical to evaluate for pulmonary embolism (PE) as quickly as possible. He called the imaging center and ordered a stat CT angiogram which is the best and quickest test available to evaluate for PE. Of course this requires pre-approval by her insurance company which will take at least 3 days. The imaging center decides to go ahead with the scan anyway while awaiting this approval based on the urgency required for diagnosis. The scan fortunately comes back negative for pulmonary embolism, and it turned out the pain was likely chest wall in origin.

The insurance company refused to pay for the CT exam however and the patient received a letter indicating that the exam was "not medically necessary". Ultimately a "peer-to-peer" discussion was required to try to get approval. The physician's point of view was that the test was urgently required because of the potential danger of a serious diagnosis. The insurance company's physician said that the attending doctor "should have" ordered a duplex ultrasound study of the legs first and then possibly a ventilation-perfusion lung scan, (which are often more difficult to get done on a stat basis for an outpatient).The reasons of course are that this would save money and save the patient radiation exposure.

The reviewing physician "peer", who haughtily announced that she was a radiologist (with the implication that a lowly internist with 30 years of hospital and office experience could not know nearly as much about how to take care of patients with potential pulmonary embolism as she does) was quite arrogant and kept interrupting the attending as he was trying to make his case and explain the situation indicating that he thought the standard of care in this community was that when suspicions are high enough, the most expeditious way of making this diagnosis should be done - in this case, that would be to get the CT angio. To do the other studies would have wasted even more precious time. Furthermore if the ultrasound studies and the lung scan were non-exclusive which they usually are not, the CT would still have been required, costing even more money and more radiation exposure.

The reviewing physician's standpoint was that the standard of care should be changed because a lung scan would have been perfectly adequate in this situation, that lung scans have just gotten a bad rep in the past and that they should be done first in these situations. (I personally cannot remember the last time I saw a "normal" lung scan that effectively excluded a pulmonary embolus, and I've ordered many hundreds of lung scans over the years.)

I wonder whose neck would have been on the line in court had the physician waited until the ultrasound and the lung scan could be done and the patient died of a pulmonary embolism that evening. Would it be the physician reviewer (the radiologist)? I don't think so.

If the patient had gone directly to the Emergency Room and the CT angiogram had been ordered by an ER physician, there would be no question that it would have been approved. Had she been admitted to the hospital for an urgent evaluation, there would have been no question about approval. Also, if the CT had shown evidence of PE, there would have been no question. Furthermore, I am not aware of any medical literature that says a patient must have an ultrasound of the legs and a lung scan before doing a CT angio in every case.

I guess the moral of the story is that any patient who calls or comes to the office with this presentation should go directly to the ER instead of trying to do anything on an outpatient basis, not necessarily because it's better care, but because the insurance won't pay for the workup otherwise.

The complexities of patient care are easy to see here. Not only do we have to know about all the intricacies of medical science, but we have to deal with the insurance company denying payment for what we judge to be the correct thing to do for our patients. Which entity has the patient's best interest in mind? Who should be in the position of establishing standards of care? The current holder of this position appears to be the insurance company.

This page was last updated on January, 21, 2012.

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