Medical necessity often requires nuanced interpretations based on an individual’s medical history that considers appropriate, reasonable and necessary healthcare interventions. While insurance companies typically utilize a finite criterion that meets medical necessity, physician advisors are indispensable for safeguarding reimbursement to ensure that healthcare organizations can continue providing quality care. Continue reading to see how AppriseMD was able to overturn a denial that the payer qualified as being not medically necessary.
CLINICAL SUMMARY:
A patient returned to the hospital five days post-surgery with uncontrolled pain, swelling in lower extremities and difficulty walking. Upon arrival, the 58-year-old female with history of anxiety, depression, DJD, L4-L5 fusion who had recently undergone a left total hip replacement was mildly tachycardic and experiencing tachypnea with exertion. Doctors saw no signs of infection on the incision site, and they performed a venous duplex ultrasound of the left lower extremity. This revealed a nonocclusive left femoral vein thrombus. Additionally, doctors ordered a chest CTA which indicated bilateral subsegmental pulmonary embolism without signs of heart strain. The patient’s initial labs showed CRP was 8.4, Pro-Cal 0.04, sed rate 49, troponin less than 6, proBNP 171, white blood cell count 7.35 and hemoglobin 10.5. The examining team recommended admission for anticoagulation and pain management. Doctors treated the patient with continued oral Keflex, initiated IV Heparin, and then transitioned the patient to oral anticoagulation upon discharge.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe patient’s insurance provider denied the inpatient stay, stating that it was not medically necessary, and that the facility was not in the patient’s plan network. The payer also stated that an observation level of care was appropriate due to the medical record not meeting inpatient level of care guidelines and criteria. Further, the denial stated that symptoms did not worsen while the patient was in the hospital; the patient was not confused or unable to drink liquids; the patient did not exhibit any dangerously abnormal vital signs; the patient did not require breathing help; and no emergency procedure or surgery was performed. All of which, the payer concluded, disqualified for inpatient level of care.
THE APPRISEMD METHOD
THE APPRISEMD METHODAppriseMD’s physician advisor completed a peer-to-peer discussion with the insurance medical director and successfully overturned the denial. Reiterating the patient’s medical history and recent surgery, the physician advisor argued that inpatient level of care was required. The physician advisor also reminded the payer medical director that a bilateral pulmonary embolism was found while the patient was in the emergency department, and that a Heparin infusion was started upon admission. Even though the patient was hemodynamically stable and did not require pulmonary embolism interventions beyond anticoagulation, the bilateral nature of the pulmonary embolism, coupled with the recent surgical intervention, justified the inpatient level of care. The payer agreed and reversed the denial.