There are not enough accolades to express the honor it is to be a Certified Legal Nurse Consultant. My pathway deviates slightly from other Certified Legal Nurse Consultants, as I review medical records for medical necessity. However, if I should come across a case with merit for malpractice, the attorneys want to know immediately. After a thorough discussion of my findings the attorneys report the findings to our client’s legal department.
The patient was receiving factor IX and developed antibodies, which required increased doses and bridging with factor VII. The reason for the denial was experimental, due to the dosing going over the normally recommended pharmaceutical prescribed amount. Each dose of factor cost $55,000.
I was asked to participate in the collaborative effort to pursue payment. The owner of the firm was the lead attorney on this case and my boss. When discussing the case with our client, I asked if the patient was receiving treatment at home and if so, did the insurance company pay for the treatment in its entirety and the answer was yes. This was the same treatment and dose being administered inpatient. My boss smiled and later stated “that was a brilliant question,” because that gave him some ammunition to start with.
The child had been receiving factor IX and developed high inhibitors to the medication resulting in a neutralization of antibodies to the factor rendering it non effective. The baby suffered a severe intracranial hemorrhage followed by several strokes.
When discussing this case with the hospital administration, I asked if it was possible to obtain a written letter from the physician as to his rationale for specialized dosing. While awaiting the physician’s response I researched evidence-based practice and date of FDA approval for NovoSeven.
NovoSeven was approved July 7, 2014. This was before the child’s date of services occurred, which was from 2015-2016. Therefore, once a drug is FDA approved it cannot be considered experimental or investigational. As for the dosing of NovoSeven, the research on bridging this drug was in accordance with evidence-based practice, which states increased dosing is necessary until the desired effect occurs.
The physician submitted his rationale for such dosing, which was backed by the medical and scientific advisory Council (MASAC) of the national hemophilia foundation. The foundation noted NovoSeven is the only bypassing, suitable, prophylaxis, optimal therapy in children with hemophilia B with factor 9 inhibitors. The physician noted the dose can vary ranging from 90-to 70 mcg per kilogram every 2-6 hours depending on the severity and frequency of bleeds. As previously noted, the child had significant bleeds.
The research articles I found and the letter from the physician was enough evidence to support the physician’s rationale for bridging and high dosing. The above evidence was presented to a mediation review board that resulted in full payment of $40 million dollars.
I was humbled to play an intricate part in this case that resulted in a success story. Becoming a Certified Legal Nurse Consultant opens the door to new pathways and great adventures.
Guest Blogger Profile
Debora Cooley, RN, CLNC is a medical necessity specialist with 45 years’ nursing experience in emergency, trauma flight, labor and delivery, interventional radiology and case management.
P.S. Comment here to congratulate Debora on her CLNC Success.