“Needs Prior Auth”

Laura Lyons has been in and out of the hospital, the emergency room and her surgeon’s office for the past month.

A cautious, thin woman in her early sixties, Laura had experienced indigestion often, but what she had a month ago was different. She was diagnosed with acute inflammation of the gallbladder and had it removed urgently. The laparoscopic procedure seemed to go well, but shortly thereafter she had to be admitted with severe nausea and abdominal pain again. Even the injections in the emergency room didn’t control her symptoms, so the surgeon put her back in the hospital for a couple of days.

The tests showed no abscess, no remaining little gallstones in the bile duct and no bile leak. The radioactive scan showed that a fair amount of bile traveled from the duodenum to the stomach, and her surgeon prescribed an acid blocker. She seemed to get a little better and went home to recover.

About a week ago Laura developed an infection of her abdominal wall and she got some antibiotics, which seemed to help. Then the nausea and vomiting came back.

When I saw her late in the afternoon the other day she didn’t think the stomach pills were helping. She had been running a low-grade fever on and off and she had a rash, consisting of little red bumps on her torso and arms. I did a careful physical exam but made no other unusual observations to help with the diagnosis.

I racked my brain trying to find the connection between all her symptoms. I got hold of the surgeon and he didn’t know either. She needed more tests and I prepared the orders for her. If she hurried, she could still get them before the hospital lab closed. We agreed that if the shot we gave her in the office for nausea didn’t work, she should go to the ER instead of the lab.

The next morning I saw the lab tests I had ordered, and they were all normal. There were a few extra blood tests, also normal, with one of the emergency physicians listed as the ordering doctor. A few hours later there was a CT scan, also normal. Around 4 o’clock we got reports from an upper and lower endoscopy, showing nothing that would cause nausea, vomiting, fever or abdominal pain, let alone a rash. On the last page, there was only one paragraph. Under the heading “Cityside Hospital, Operative Report” was the surgeon’s conclusion that the patient’s symptoms were probably due to bile reflux into the stomach after all, and she needed to take a double dose of her acid blocker under close supervision by her primary care physician.

At 4:30 we got a fax from the pharmacy. The acid blocker prescription was rejected by Laura’s insurance. The pharmacist had written in bold ink “NEEDS PRIOR AUTH”. The prescription information had the surgeon’s name on it, but it was crossed out and replaced with mine. As I looked closer at the fax, I noticed two numbers at the top of the page. The pharmacy had faxed it to the surgeon and the surgeon had faxed it to me.

So this is where the buck stops, I thought to myself as I printed up the usual Prior Authorization form from the Medicaid website. I filled in the diagnosis “Bile reflux, post cholecystectomy with complications” and attached the last page of her endoscopy report with the surgeon’s comments about intensifying her acid blocker treatment. I do know how to jump through insurance companies’ hoops, or maybe I just have more patience with them than surgeons do.

I still don’t know what is causing Laura’s symptoms, but the surgeon clearly signed off by saying she needs high-dose acid blocker treatment under close supervision by her primary care physician.

After the holiday, I need to take a fresh look at poor Laura Lyons.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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