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The "Independent" Case Review by an "Expert"

 

This case represents all the elements of poor practice by physician serving as a reviewer for a managed care organization.  This is a circumstance where the patient's treating spine specialist has recommended treatment by a minimally invasive electrothermal coagulation (IDET).  
The reviewer is a Orthopedic surgeon.  His areas of specialty as evidenced by his letterhead are "joint replacement, sports medicine, and orthopedic trauma"; not spine care.  Part of the physician's letter justifying the denial of medical coverage for the procedure is shown below:


The key reasons as to why this review lacks merit are:

The physician lacks qualification on the basis of training and experience to provide an "expert" opinion.
The physician did not perform an examination of the patient and a "paper" review is unacceptable for the purposes of diagnosis, treatment, or "expert" review.
The physician is ill-informed.  He does not understand the meaning of the word "experimental."
The physician is ill-informed.  Not being a specialist in the field he is unaware of publications and presentations relevant to the subject.
It remains entirely possible that the patient in question is not an optimal candidate for the treatment being recommended.  The patient is deserving, however, of an opinion by a qualified specialist.  IDET has not yet become a standard procedure but a spine care specialist might be able to make better treatment recommendations. The point is that the review in question was worthless from the standpoint of utilization review.  The costs inherent in this review most probably exceeded the treatment prescribed.

Another significant observation is that IDET is a minimally invasive procedure and that the patient, if they were well-informed and wished to have it done should have the freedom to do this if they were spending their own money from a MSA.  

The process presented above is not only disrespectful to the patient but also the treating specialist who recommended IDET, as well as the community in general.