March 2026

Formal written appeals of an upheld peer-to-peer

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer

Case Study, Denial Management, Formal Appeal, Peer-to-Peer / By

THE CHALLENGE Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient […]

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AppriseMD Case Study Challenging MA denial overturned despite one-midnight stay

Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay

Case Study, Two-Midnight Rule / By

CLINICAL SUMMARY: A 76-year-old female arrived at the emergency department critically ill, experiencing palpitations and shortness of breath. The patient had a complex medical history including ovarian and thyroid cancers, chronic heart failure (CHF) with reduced ejection fraction (EF 20%), stage 3b chronic kidney disease, gastroesophageal reflux disease, paroxysmal atrial fibrillation (A-fib) on anticoagulation, type 2

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