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Melanie Cole (Host):  Welcome. Today we’re discussing prior authorizations for abdominal pain in Convenient Care Plus. And my guests in this panel discussion are Dr. Charles Liang. He’s the Associate Medical Director for Health Alliance and Dr. Jay Jimenez, he is the Associate Medical Director of Radiology and they are both at the Carle Foundation Hospital. Gentlemen, I’m going to kind of let you take it from here because this is a panel discussion. Dr. Liang, would you like to start? Go for it.

Charles Liang, DO (Guest):  So, today, we’re here to talk about prior authorizations in Convenient Care Plus and a number of questions come up about which test to order and what things need to be included in the documentation so that the prior authorization can go through and also there’s an issue of retrospective audits. So, Jay, thanks for coming on today with me. And I just wanted to kind of get the radiology perspective on this too. So, we’ll just start with some hypothetical cases. If that’s okay.

We will start out with the classic, the right upper quadrant pain that is suspicious for gallbladder and then, what sort of things would you like to see us order? What sort of things make sense from a radiology perspective?

Juan Jimenez, MD (Guest):  Obviously, for every type of abdominal pain, there can be multiple different exams to order and in this case of acute right upper quadrant abdominal pain, where gallbladder disease is felt to be the most likely differential consideration; we’d like to start off with limited or gallbladder ultrasound, also known as a right upper quadrant ultrasound or abdomen limited ultrasound.

Dr. Liang:  And then what happens if that comes back equivocal like for example there’s no stones, but they still have this right upper quadrant pain? Where would you go to next?

Dr. Jimenez:  Well I think that’s where you have to start dialing in exactly what you’re looking for. If we are still really concerned about gallbladder disease; a lot of times the nuclear medicine HIDA scan would be the next step in a case of ongoing right upper quadrant abdominal pain with a negative ultrasound. Certainly CT can be considered in that situation particularly if there’s – it’s a very acute onset or maybe there are alterations in liver function tests or a laboratory panel that suggests cholestasis.

Dr. Liang:  So, you mentioned CT, so if you get a CT of the abdomen, do you have to get the pelvis too or can we just get CT of the abdomen with contrast?

Dr. Jimenez:  We can scan just the abdomen and we scan the abdomen and pelvis and kind of our approach and the way we have our protocols set up is that for most garden variety cases of acute abdominal pain; what we would classify as the abdominal pain not otherwise specified or generalized abdominal pain without any particular organ system at fault; we would encourage people to get the full abdomen and pelvis with IV and oral contrast. Now in the setting of a particular upper quadrant pain like right upper quadrant, left upper quadrant or in the setting that we want to evaluate a particular organ system such as the liver or the kidneys or the pancreas; then we would limit the scanning to the upper abdomen. But for most general abdominal pain cases, we do want to scan the entire abdomen and pelvis.

Dr. Liang:  You touched on the left upper quadrant, so we can kind of move over to there. So, when you have a left upper quadrant pain that’s pretty specific and you are maybe worried about a splenic injury, what kind of imaging would you want? Would you still get an ultrasound?

Dr. Jimenez:  So, you are worried about an injury so I’m assuming there’s been some acute injury, acute trauma to the region. CT with contrast is typically our go to exam. While we would be tempted to limit the scanning to the upper abdomen; in that case; I would caution people particularly in the setting of trauma to include the pelvis because there can be a significant amount of bleeding that occurs from splenic injuries and omitting the pelvis from scanning can inhibit our ability to assess for intraperitoneal hemorrhage.

Dr. Liang:  I think I remember a case that I saw in Convenient Care where they – it was a trampoline injury and the patient actually did have bleeding intraperitoneally like you mentioned. And now, we’ll just kind of keep going counter clockwise and talk about left lower quadrant pain. So, if you are thinking about like diverticulitis or something what sort of test do you think we should order?

Dr. Jimenez:  Diverticulitis we do a lot of that scanning in the acute setting both from Convenient Care and the ED. In that particular setting, we would want to image the entire abdomen and pelvis with IV and oral contrast. Oral contrast is one of the sort of controversial areas in abdominal imaging and over the years, we’ve relaxed our requirement on that. We have a protocol set up through the emergency department which we could easily apply to Convenient Care that’s based primarily on indication and body mass index. So, as a general rule, younger and thinner patients benefit more from oral contrast than older heavier patients. Because the intraperitoneal fat acts as a contrast agent in itself when evaluating the bowel. So, definitely want the IV contrast. Oral would be a plus or minus depending on age, body mass index and that kind of thing.

Dr. Laing:  So, you are saying if someone is thin, you would want the oral contrast?

Dr. Jimenez:  Yes. We would prefer to have that because the – in a thin patient, particularly in a female patient who tend to have less intraperitoneal fat anyway; the bowel loops are in very close approximation to one another and if they are not opacified with contrast; it can be very difficult to determine if there’s any kind of inflammatory process going on such as free fluid or even an abscess. So, in those cases, we really want to have the oral contrast.

Dr. Liang:  Wow, that’s really interesting. One thing I’ve heard before is that people are concerned that if they – if someone has a ruptured diverticula, wont the oral contrast spill into the cavity and would that obscure the view, or would that be toxic to the colon in some way?

Dr. Jimenez:  The whole concept of what we call barium peritonitis, the standard ready cat oral contrast agent is a barium based agent. What we tend to do in the acute setting through the emergency department and through Convenient Care is we actually use diluted water soluble iodinated IV contrast that’s taken orally. And what this does is if there is a bowel perforation and gets into the peritoneal cavity; it’s relatively harmless and becomes – it just gets absorbed. Where as the barium compounds can cause an additional problem if there’s a perforation.

Dr. Liang:  Okay so when they are ordering it, is that going to be an automatic?

Dr. Jimenez:  No, in the acute setting, our imaging protocols are set up so that if it’s a stat ED or Convenient Care, even a stat outpatient; we tend to use the water soluble contrast agents which is basically diluted Omnipaque. Occasionally we will use the diluted Gastrografin, but we’ve really transitioned more towards the diluted Omnipaque for oral contrast.

Dr. Liang:  That’s really helpful to know. Then right lower quadrant pain, like you were thinking about an appendicitis.

Dr. Jimenez:  Obviously IV and oral contrast is preferred. We can probably again get away with IV contrast only in the setting of a larger patient and again, we have established guidelines through the emergency department that the providers can reference if they have any questions about that.

Dr. Liang:  What about an ultrasound if you are thinking about appendicitis? Do you see that? Specifically for like a kid.

Dr. Jimenez:  In pediatric patients, or in a young adult, a young female; ultrasound is always a good place to start for lower quadrant abdominal pain particularly in a female patient where we want to rule out gynecologic etiologies that may mimic appendicitis. So, the pelvic ultrasound in a female is always a very good place to start. If that’s negative or we have concerns and need to progress to a CT scan because we think appendicitis; there is a specified ultrasound protocol for appendicitis that we can utilize. I can tell you our sensitivity isn’t great with that. But if it’s positive; if we can see an abnormal appendix; usually our surgeons are happy to operate based on that finding. If not, if we need to progress to CT scan; IV and oral contrast is preferred in those situations.

Dr. Liang:  Sometimes people come in with this epigastric pain thing. They have a really severe type heartburn and it’s kind of not always clear to us what we should image on those patients. Or if they need imaging at all. If they don’t have any red flags, which would include high fever of 101 or greater, cancer history, GI bleeding, severe tenderness or guarding; then what kind of testing do you think we ought to be doing for those patients?

Dr. Jimenez:  For epigastric pain, I think the one thing that we want to make sure that we’re ruling out – well there are two entities really. Pancreatitis and peptic ulcer disease. And not sure why, but I’ve seen an uptick of perforated duodenal ulcers and gastric ulcers in the last two years. I almost have a series of cases going on with that right now. But a CT of the upper abdomen with IV and oral contrast would be preferable in that situation. Obviously with pancreatitis, we would prefer to have laboratory values that would support that diagnosis before proceeding with the CT, but I think that the upper abdomen CT with contrast is definitely the way to go there.

Dr. Liang:  Wow, that’s excellent. That’s super helpful.  I think that kind of covers pretty much covers the abdominal exam series. Is there anything else you would like to add in closing?

Dr. Jimenez:  Just that the radiology department in kind of going around this Convenient Care Plus concept. We are committed to making sure these patients are getting the care they need in a timely manner. To that end, maybe you can speak to this from the Health Alliance perspective; we are trying to streamline the prior authorization process because these are outpatients. So, I mean during the business day; I think we do try to put those through for a prior auth a stat prior auth, but we are not going to delay scanning, waiting for that to come back and as you had mentioned at the beginning of the talk; we are doing some background audits to make sure that these are meeting criteria. I can say with the clinical decision support system in place, that should really guide the clinicians to ordering the appropriate test so if it goes through the CDS process, chances are it’s going to be approved by eviCore.

Dr. Liang:  Right and then it can always be appealed if they are turned down. Okay, well that’s great. Thank you so much for coming on with us today. I think this is going to be really helpful for our Convenient Care Plus Providers.

Host:  Wow, thank you so much gentlemen. What an interesting segment for other providers to hear two providers discussing this in such detail. Thank you again for joining us. And that wraps up this episode of Expert Insights with The Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at www.carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media, share with other providers and be sure to check out all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.