Lyme disease in neurology – a primer

Posted on November 25, 2024 by Maurice Preter MD

Here is a detailed summary of the key points about Lyme disease and its neurologic complications:

Causative agent and transmission:

  • Caused by spirochetes of the genus Borrelia, primarily Borrelia burgdorferi in North America
  • Transmitted by bite of infected Ixodes tick
  • Tick must typically remain attached for 24-48 hours to transmit Borrelia

• Geographic distribution:

  • Highest incidence in northeastern and north-central United States
  • Endemic areas include Connecticut, Vermont, Maine, Massachusetts, New Hampshire, Rhode Island, New Jersey, Pennsylvania, New York, Wisconsin, Minnesota

• Clinical manifestations:

  • Initial sign is often erythema migrans rash at site of tick bite
  • Can progress to systemic involvement if untreated
  • Most common neurologic complications:
    1. Cranial neuritis (especially facial nerve palsy)
    2. Meningitis
    3. Radiculoneuritis/mononeuropathy multiplex

• Diagnosis:

  • Two-step serologic testing recommended by CDC:
    1. Enzyme-linked immunosorbent assay (ELISA)
    2. If ELISA positive/borderline, Western blot for IgM and IgG
  • CSF analysis may be needed in early infection or equivocal cases
  • CSF typically shows lymphocytic pleocytosis in active neuroborreliosis

• Treatment:

  • Oral doxycycline for most cases of neuroborreliosis
  • IV antibiotics (ceftriaxone, cefotaxime, penicillin G) for severe manifestations
  • Duration typically 2-4 weeks

• Post-treatment Lyme disease syndrome:

  • Persistent symptoms like fatigue, pain, cognitive issues after treatment
  • Not indicative of ongoing infection
  • No benefit from prolonged antibiotic therapy

• Chronic Lyme disease controversy:

  • Not a recognized clinical entity
  • Symptoms attributed to Lyme without evidence of infection
  • Long-term antibiotics not recommended

• Key points for neurologists:

  • Consider Lyme in endemic areas for patients with facial palsy, meningitis, radiculitis
  • Understand proper diagnostic testing and interpretation
  • Recognize limitations of serology in early infection
  • Be aware of guidelines for appropriate antibiotic treatment
Posted in News |

Essential tremor is a complex neurological disorder characterized by rhythmic shaking, primarily affecting the hands, head, and voice.

Posted on November 25, 2024 by Maurice Preter MD

Essential tremor is a complex neurological disorder characterized by rhythmic shaking, primarily affecting the hands, head, and voice. Here’s a comprehensive overview of its diagnosis and management:

Clinical Manifestations

Limb Tremor

Essential tremor primarily manifests as a bilateral upper extremity action tremor. Key features include:

  • Kinetic tremor with or without postural tremor
  • Frequency between 8-12 Hz
  • Kinetic tremor more severe than postural tremor in about 95% of cases
  • Mild to moderate asymmetry common
  • Rest tremor possible in longstanding cases (prevalence 2-46%)
  • Intention tremor may develop later, associated with disease duration

Head Tremor

Head tremor is a common late manifestation:

  • Present in about 39% of patients
  • More common in women and older patients
  • Often exacerbated during phonation tasks
  • May have an intention component
  • Can be “no-no” (horizontal), “yes-yes” (vertical), or mixed directional

Vocal Tremor

Vocal changes are frequent, especially in older patients:

  • More common in women
  • Patients describe voice as “weak,” “unstable,” “shaky,” or “hoarse”
  • Can involve muscles of the palate, pharynx, tongue, and larynx

Other Manifestations

  • Chin/jaw tremor: Uncommon, increases with disease severity
  • Balance difficulties and gait impairment
  • Hearing loss: Higher prevalence of hearing impairment and hearing aid use
  • Olfactory changes: Mixed findings, may be normal in many cases
  • Eye findings: Oculomotor changes, including square wave jerks and altered saccades

Psychiatric and Cognitive Symptoms

  • Higher rates of depression, anxiety, and sleep disturbances
  • Increased pain severity and interference
  • Mild cognitive impairment, particularly in executive function, attention, and working memory

Diagnosis

Essential tremor is primarily a clinical diagnosis based on history and examination:

  • Assess tremor during different activities and impact on daily living
  • Family history and alcohol responsiveness can be helpful clues
  • Perform multiple bedside tests (e.g., arm extension, finger-to-nose movements, spiral drawing)
  • Complete neurological examination to rule out other conditions

Diagnostic pearls:

  • Extension-flexion at the wrist during arm extension
  • Intention tremor in finger-to-nose testing (>25% of cases)
  • Characteristic axis in writing and spiral drawings (8-2 o’clock for right-handed, 10-4 o’clock for left-handed)
  • “Head snap” during finger-to-nose examination in up to 20% of cases

Classification

The International Parkinson and Movement Disorder Society redefined essential tremor in 2018 as a syndrome, recognizing its heterogeneity. The new classification includes:

  • Essential tremor
  • Essential tremor plus (with additional neurological signs)

Treatment

First-line treatments:

  • Propranolol
  • Primidone

For severe cases:

  • Deep brain stimulation (traditional target: ventral intermediate nucleus of thalamus; emerging target: caudal zona incerta)
  • MRI-guided high-intensity focused ultrasound

Emerging treatments:

  • Novel oral medications
  • Chemodenervation
  • Noninvasive neuromodulation

Prognosis

Essential tremor is progressive, but less than 10% of patients with long disease duration develop significant disability. Predictors of faster progression include:

  • Longer disease duration
  • Asymmetrical tremor
  • Isolated limb involvement at onset
  • Older age of onset

In conclusion, essential tremor is a complex and heterogeneous disorder requiring careful clinical assessment for accurate diagnosis and appropriate management.

 
Posted in Psychiatry/Neurology | Tagged , |

Here’s a comprehensive guide on how to effectively utilize out-of-network health insurance benefits for psychotherapy in New York City

Posted on November 11, 2024 by Maurice Preter MD

Here’s a comprehensive guide on how to effectively utilize out-of-network health insurance benefits for psychotherapy in New York City:

Understanding Out-of-Network Benefits

Out-of-network benefits allow you to see healthcare providers who are not in your insurance plan’s network. While you may pay more upfront, you can often receive reimbursement from your insurance company[1][3].

Key benefits of using out-of-network providers include:

– Greater flexibility in choosing a therapist
– Access to specialists who may not be in-network
– Potentially shorter wait times for appointments
– More control over your treatment plan

Steps to Use Out-of-Network Benefits

1. Check your out-of-network benefits[8]:
– Review your insurance policy documents
– Look for information on behavioral health or mental health coverage

2. Call your insurance company to verify benefits[8]:
– Ask about your out-of-network deductible for mental health services
– Inquire about coinsurance rates for out-of-network providers
– Confirm if you need a referral from an in-network provider
– Ask about the process for submitting claims

3. Find a therapist:
– Ask for recommendations from trusted sources
– Use online directories to find therapists in NYC
– Schedule initial consultations with potential therapists

4. Discuss fees and insurance with your chosen therapist:
– Ask if they offer sliding scale fees
– Inquire about their experience with out-of-network claims

5. Pay for sessions upfront:
– Most out-of-network providers require full payment at the time of service[1]

6. Obtain a superbill from your therapist:
– This detailed receipt contains necessary information for insurance claims[8]

7. Submit claims to your insurance company:
– Follow your insurer’s process for submitting out-of-network claims
– Some therapists may offer to submit claims on your behalf for a fee[3]

8. Receive reimbursement:
– Your insurance company will process the claim and send you reimbursement based on your plan’s out-of-network benefits[8]

Important Considerations

– Out-of-network deductibles are often higher than in-network deductibles[12]
– Reimbursement rates vary, typically ranging from 50-80% of the session fee[4]
– There may be limits on the number of covered sessions per year[6]
– Some plans have out-of-pocket maximums for out-of-network care[12]

Potential Advantages in NYC

Many therapists in New York City choose not to participate in insurance networks due to low reimbursement rates and administrative burdens[11]. This means that using out-of-network benefits can give you access to a wider pool of experienced therapists.

Tips for Maximizing Benefits

– Keep detailed records of all sessions and payments
– Submit claims promptly and regularly
– Follow up with your insurance company if reimbursements are delayed
– Consider using health savings accounts (HSAs) or flexible spending accounts (FSAs) to pay for therapy with pre-tax dollars

By understanding and effectively using your out-of-network benefits, you can potentially access high-quality psychotherapy in New York City while managing costs. Always verify your specific plan details and discuss options with potential therapists to make the most informed decision about your mental health care.

Citations:
[1] https://www.zocdoc.com/blog/what-does-it-mean-to-get-an-out-of-network-therapist/
[2] https://uncovercounseling.com/blog/out-of-network-vs-in-network-therapy-in-nyc/
[3] https://crowncounseling.com/out-of-network-coverage/
[4] https://blog.zencare.co/a-therapists-guide-to-out-of-network-benefits/
[5] https://www.integrative-psych.org/out-of-network-reimbursement-a-comprehensive-guide
[6] https://www.nyc.gov/site/doh/health/health-topics/health-insurance-behavioral.page
[7] https://www.gatewaytosolutions.org/about-therapy/using-your-out-of-network-insurance-benefits/
[8] https://blog.zencare.co/guide-to-out-of-network-benefits/
[9] https://mywellbeing.com/therapy-101/insurance
[10] https://byrepose.com/check-your-out-of-network-benefits
[11] https://tribecatherapy.com/1449/out-of-network-psychotherapy-nyc/
[12] https://blog.opencounseling.com/out-of-network-therapist-tips/

Posted in News, Psychiatry/Neurology |

Guide to out-of-network health insurance benefits to obtain neuropsychiatric care

Posted on November 11, 2024 by Maurice Preter MD

Out-of-network health insurance benefits can be effectively utilized to obtain neuropsychiatric care in New York City.

Here’s a comprehensive guide on how to navigate this process:

Understanding Out-of-Network Benefits

Out-of-network benefits allow you to see healthcare providers who are not in your insurance plan’s network, including neuropsychiatrists. While you may pay more upfront, you can often receive substantial reimbursement from your insurance company.

Key Steps to Utilize Out-of-Network Benefits

1. **Verify Your Coverage**: Contact your insurance company to confirm your out-of-network benefits for neuropsychiatric services.

2. **Understand Your Deductible**: Know the amount you need to pay before your insurance starts covering costs.

3. **Check Reimbursement Rates**: Ask your insurance about the percentage of out-of-network costs they’ll cover. Typically, insurance reimburses 50-80% of the cost per service after the deductible is met.

4. **Find a Neuropsychiatrist**: Many reputable institutions in NYC offer comprehensive neuropsychiatric services. Private practitioners are few and far between, but do exist.

5. **Pay Upfront**: You’ll typically need to pay the full fee at the time of service.

6. **Obtain a Superbill**: After your session, request a detailed receipt (superbill) from your neuropsychiatrist. This document should include all necessary information for insurance submission.

7. **Submit Claims**: File your claims promptly to ensure timely reimbursement. You can usually do this online or by mail.

Important Questions to Ask Your Insurance Company

When contacting your insurance provider, ask the following:

– Do I have out-of-network benefits for neuropsychiatric services?
– What is my out-of-network deductible, and how much have I met so far this year?
– What is my out-of-network coinsurance for neuropsychiatric services?
– Is there a limit on the number of sessions covered per year?
– Do I need pre-authorization for neuropsychiatric services?

Relevant Billing Codes

When discussing coverage with your insurance, you may need to reference these common billing codes for neuropsychiatric services:

– 90792: 90-minute initial psychiatric diagnostic evaluation
– 99213 + 90836: 45-minute follow-up sessions (includes therapy and medication management)
– 99213 + 90833: 30-minute follow-up sessions (medication management only)

Tips for Successful Claims Submission

1. Submit claims regularly, ideally after each session.
2. Double-check all information for accuracy before submitting.
3. Keep copies of all submitted claims and correspondence.
4. Follow up with your insurance company if you haven’t received a response within 30 days.
5. Be prepared to appeal if a claim is denied.

Potential Benefits of Using Out-of-Network Coverage

1. **Wider Provider Selection**: You have access to a larger pool of neuropsychiatrists, allowing you to choose based on expertise and specialization.

2. **Flexibility**: You’re not limited to in-network providers, which can be particularly beneficial when seeking specialized neuropsychiatric care.

3. **Quality of Care**: You can prioritize finding the best neuropsychiatrist for your needs without being restricted by network limitations.

Remember, while using out-of-network benefits may require more upfront costs and paperwork, it can provide access to high-quality neuropsychiatric care in NYC that might not be available within your network. Always verify your specific coverage details with your insurance provider, as benefits can vary significantly between plans.

Posted in News, Psychiatry/Neurology | Tagged , |

Neuropsychiatric symptomatology in Parkinson’s Disease (PD)

Posted on November 11, 2024 by Maurice Preter MD

Here are the key points about neuropsychiatric symptoms in Parkinson’s disease (PD):

1. Prevalence and common symptoms:
– Neuropsychiatric symptoms are very common in PD, affecting up to 89% of patients at some point[1][7].
– The most frequent symptoms are depression, anxiety, apathy, hallucinations, and impulse control disorders[1][2][5].
– Depression affects approximately 30-40% of PD patients[6].
– Anxiety affects up to 40% of PD patients[6].
– Apathy prevalence ranges from 17-70% depending on diagnostic criteria used[7].

2. Impact:
– Neuropsychiatric symptoms significantly impact quality of life, daily functioning, and caregiver burden[1][9].
– They are associated with increased risk of nursing home admission[1].
– Depression and anxiety scores are closely linked to patient-perceived health status[6].

3. Characteristics:
– Symptoms can occur at all stages of PD, even in early/prodromal phases[3][7].
– Depression and anxiety can be “off-period” related phenomena, fluctuating with motor symptoms[6].
– Apathy is characterized by emotional indifference, reduced activity/interest, and lack of concern for others[7].

4. Underlying mechanisms:
– The pathophysiology is likely multifactorial, involving dopaminergic, serotonergic, noradrenergic and cholinergic systems[6][8].
– Neuroimaging studies show alterations in various brain regions/networks for different symptoms[3][8].

5. Diagnosis and assessment:
– Diagnosis can be challenging due to symptom overlap with PD motor symptoms[6][7].
– Validated assessment scales are now available for most symptoms[2].

6. Management:
– Treatment involves both pharmacological and non-pharmacological approaches[2].
– Balancing dopaminergic therapy is important, as it can improve some symptoms but exacerbate others[2].

7. Prognosis:
– Psychiatric symptoms like psychosis, depression and apathy are associated with poorer outcomes including cognitive decline and disease progression[8].

In summary, neuropsychiatric symptoms are a core feature of PD that significantly impact patients’ lives. They require careful assessment and management as part of comprehensive PD care.

Citations:
[1] https://jnnp.bmj.com/content/78/1/36
[2] https://link.springer.com/article/10.1007/s40263-018-0540-6
[3] https://www.nature.com/articles/s41398-024-03070-z
[4] https://www.frontiersin.org/journals/neuroscience/articles/10.3389/fnins.2020.00025/full
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC9110237/
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC2787875/
[7] https://www.cambridge.org/core/journals/bjpsych-advances/article/neuropsychiatric-symptoms-in-parkinsons-disease-aetiology-diagnosis-and-treatment/E8BBA87713D9DC93E65D7AB1929CC00B
[8] https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(24)00036-X/fulltext
[9] https://www.mdpi.com/2076-3425/12/1/89

Posted in Aging, Psychiatry/Neurology | Tagged , , , |