CASE STUDIES

Difficult inpatient-stay denials

CLINICAL SUMMARY: Total knee replacement

A 67-year-old patient underwent a left total knee replacement and was admitted to the orthopedic floor and monitored by the internal medicine team for a two-day hospital stay following the operation. The patient was placed on Lovenox and Eliquis for deep vein thrombosis (DVT) prophylaxis. Postoperative X-rays showed the prosthetic components fixed and in good position; activity began the night of the procedure. On postoperative day one, the patient continued to ambulate with PT and was able to bear weight on both legs. Pain was controlled using a multimodal approach of oral medications. PT remained unremarkable and the patient was cleared medically and orthopedically for discharge after two midnights.

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DENIED INPATIENT STAY

The insurance company did not provide a reason for denying the LOC for the hospitalization for the TKA procedure.

PEER-TO-PEER DISCUSSION

An AppriseMD physician advisor spoke with the insurance company medical director regarding the denial. The patient’s medical history was discussed during the call, including the patient’s coronary artery bypass graft surgery in 2021, hypertension, Hodgkin’s lymphoma and obstructive sleep apnea. The patient did not have any significant postoperative complications and was discharged after two midnights. After a lengthy conversation, AppriseMD was able to overturn the denial due to the significant medical history which made this patient a higher risk for the procedure.

The Peer-to-Peer discussion resulted in the approval of an inpatient level of care, overturning the denial. However, the insurance company did raise quality concerns with this case. The patient required a higher level of care and multiple days were spent waiting on transfer to a higher level of care at the university hospital. The insurance company medical director felt it was important to seek alternate centers if no beds were available initially and saw the need for a quality review.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Type 2 diabetes and chronic kidney disease

A 40-year-old patient arrived in the Emergency Department complaining of worsening right upper quadrant abdominal pain with a hard lump in the epigastric area. The patient – who has a history of Type 2 diabetes, hypertension, necrotizing, pancreatitis, and chronic kidney disease – suffered symptoms for approximately one week. The patient was on insulin and regularly visited a pain clinic for chronic pancreatitis.

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Clinical Summary Continued:

Doctors performed a CT scan which showed a new peripherally enhancing fluid collection in the right upper quadrant of the abdomen adjacent to a pancreatic pseudocyst possibly suggestive of an abscess formation as well as an increase in the size of the pancreatic pseudocyst. General surgery was consulted for assistance and treating physicians contacted a nearby university hospital, which agreed to accept the patient for transfer but did not have a bed available. The patient was admitted as an inpatient and given Dilaudid for pain, awaiting a call back when a bed was available at a university hospital.

The admitting hospital continued to communicate with the university hospital about a transfer as it cared for the patient. The patient began long-acting oxycodone 10 mg every 12 hours with Norco as needed. That dosage was increased to 20 mg twice a day and Norco upped to 10-20 every four hours on the third day of hospitalization. The patient was also given 20 of IV Lasix. Doctors began discontinuing Dilaudid as pain control improved the following day. The patient was discharged after six days once there was no longer a need for IV pain medications. Doctors ensured follow-up care with a primary care provider and sent the patient home with prescriptions for insulin.

DENIED INPATIENT STAY

The insurance company medical director denied the acute care level noting the pseudocyst and a review of the patient’s records which showed a history of pancreatic problems and Type 2 diabetes. The denial letter stated the patient had been treated in the past for pancreatic problems and made note of the fact that the patient was on pancreatic enzyme replacements due to inadequate release of pancreatic enzymes into the intestines. A lower level of care was approved for the hospital stay, reasoning that the patient was waiting for a transfer to a tertiary for definitive care.

PEER-TO-PEER DISCUSSION

AppriseMD’s physician advisor spoke to the insurance company medical director regarding the case. He pointed out the fact that the patient was admitted for recurrent pancreatitis and multiple pseudocysts with possible abscess formation. Also discussed was the fact that the patient was treated with multiple doses of IV pain medications and had a surgery evaluation. Even on the third day in the hospital, the patient continued to need seven doses of Dilaudid via an IV. AppriseMD maintained that given the need for IV pain medication and IV Zosyn, care moved beyond observation care.

OUTCOME: DENIAL OVERTURNED

Even with concerns about days spent waiting on a transfer to a higher level of care, an insurance company medical director reversed an inpatient stay denial after a Peer-to-Peer discussion of the case.

CLINICAL SUMMARY: Hyperemesis gravidarum 4-day inpatient stay

A 34-year-old patient who was 13 weeks pregnant was admitted to the hospital recently with hyperemesis gravidarum with electrolyte imbalances. The patient had experienced several days of nausea and emesis; she also had a low-grade fever of 100.5 degrees with a white blood cell count of 20k and bicarb of 17. An abdominal MRI showed no appendicitis; urinalysis noted epithelial cells, moderate bacteria, trace protein and ketones. Treating physicians began ceftriaxone for asymptomatic bacteriuria. The patient experienced sudden onset back and pelvis pain with unclear etiology. She was started on morphine. A retroperitoneal ultrasound showed mild right renal fullness. Physicians consulted urology concerned for obstructing nephrolithiasis in the setting of the pregnancy. Urology concluded the patient could have recently passed a stone, but no current stone required management.

The patient’s electrolytes stabilized during the four-day stay and outpatient IV fluids were arranged for given the ongoing hyperemesis gravidarum. There was no urine culture growth, therefore antibiotics were stopped at discharge. The patient had a close obstetrics follow-up post discharge.

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DENIED INPATIENT STAY

The insurance company denied the four-day hospital stay at the acute inpatient level of care without detailed reasoning in its denial letter. Therefore, a Peer-to-Peer discussion with the medical director was scheduled.

PEER-TO-PEER DISCUSSION

An AppriseMD physician advisor conducted the P2P with the insurance medical director to discuss the patient and the denial reasoning for the hyperemesis gravidarum case. After a detailed discussion, the denial was overturned based on the amount of pain medication the patient required. The patient had severe flank pain and a stone evaluation. In addition, the patient underwent a retroperitoneal ultrasound. The urology consult felt this was not related to a kidney stone. Ultimately, the patient improved but it required significant pain medication and antiemetic medications which allowed for inpatient approval.

OUTCOME: DENIAL OVERTURNED

After overturning the denial, the insurance company medical director commented that it is very difficult to overturn these cases.

CLINICAL SUMMARY: Complications following mastectomy

A 68-year-old female was admitted to the hospital for a scheduled left mastectomy for recurrent left-sided ductal carcinoma. The patient had previously had a left-sided full axillary lymph node dissection and was treated in 2009 for her first breast cancer with adjuvant chemoradiation.

The left mastectomy was complicated by postoperative bleeding and a hematoma formation. This required a return to surgery for a hematoma evacuation and to control the bleeding. Following the second procedure, the patient had low blood pressure related to hemorrhagic shock. The treating physician gave the patient a transfusion of packed red blood cells and fluids, after which the patient improved. The patient was discharged on hospital day three in good condition with a drain in place for serosanguineous fluid. Her hemoglobin level was stable at 9.2.

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DENIED INPATIENT STAY

The three-day hospital admission, which included time in the ICU, was denied by the insurance company. The denial letter did not state the reason for the denial but approved only an observation status for this patient. However, this was an elective procedure that ended with a complication. The patient was admitted HOS (hospital outpatient services) then converted to inpatient after the patient was transferred to ICU due to complications. The denial did ask for surgical CTP codes and for more information about the procedure.

PEER-TO-PEER DISCUSSION

An AppriseMD physician advisor conducted a Peer-to-Peer discussion with the Aetna medical director to discuss the denial for this patient with a history of breast cancer. The physicians discussed the clinical notes on the case including the fact that on day one of admission, the patient had a postoperative complication of significant bleeding requiring an emergent return to the OR for evacuation of the hematoma and treatment of the pectoral artery bleed. In addition, the patient was hypotensive requiring pressors and a transfusion. She was also admitted to ICU. The day after the procedure, the patient remained hypotensive and continued to receive IV fluids and close medical and supportive care. Due to the severity of illness, intensity of service and risk for morbidity and mortality, the denial was rescinded. An inpatient status was approved.

OUTCOME: DENIAL OVERTURNED

For more information about breast cancer, visit the National Breast Cancer Foundation.

CLINICAL SUMMARY: One-day inpatient denial overturned

A 77-year-old patient with a past medical history of hypertension, hypothyroidism, and coronary artery disease with a post-stent placement was transferred to the hospital to be seen by a cardiologist due to concerns of worsening chest pain and shortness of breath. The patient initially visited an outside facility where he experienced new onset atrial fibrillation with rapid ventricular response (RVR) but was transferred to the hospital where he stayed for one day.

The patient had been on a regimen of aspirin, which he began 27 years ago, and Plavix, which was began a year ago after having episode of a stroke with no neurological deficits. The patient’s CHADS score was 4 and doctors began anticoagulation treatment with Eliquis. His atrial fibrillation was rate controlled; however, cardiology administered Amiodarone which transition him to normal sinus rhythm. The patient's echocardiogram showed a low ejection fraction (EF) of 37%. During the stay, doctors directed the patient to consistently use his CPAP machine and stop drinking alcohol. The patient showed verbal understanding of the instructions.

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DENIED INPATIENT STAY

The one-day inpatient stay was denied by the insurance company with no specific reasons stated in the denial letter. However, the denial recommended billing for an observation stay instead.

PEER-TO-PEER DISCUSSION

A Peer-to-Peer was completed between an AppriseMD physician advisor and a physician representing the insurance company. After a discussion, the insurance company physician agreed with an inpatient level of care for this patient who admitted with NSTEMI from atrial fibrillation with RVR. Although the patient did not require cardiac catheterization, based on his condition upon admission, inpatient level of care was supported. The denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Ankle Injury with Complex Medical History

A 68-year-old patient arrived in the ER with severe pain, numbness and injury to her left ankle due to a fall at home. The patient had metastatic ovarian carcinoma and was undergoing chemotherapy with carboplatin and paclitaxel. Paclitaxel dose was reduced prior to this incident due to worsening peripheral neuropathy. The last chemotherapy session was six days prior to the fall. The patient’s medical history included obesity, type 1 diabetes mellitus with an insulin pump, hypertension, hyperlipidemia, hypothyroidism, COPD, and asthma (using O2 at home). Labs were WBC 6.74; Hgb 7.6, 7.2; PLT 222; Na 133, 135; K 4.6; BUN 40, 40; Cr 1.08; and GLU 101-206.

An x-ray in the ER showed a complex fracture, dislocation of the left ankle for which the patient underwent a closed reduction and application of a splint.

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Clinical Summary continued:

Later that day, the patient underwent open reduction and internal fixation by orthopedic surgery of a trimalleolar ankle fracture. The patient was admitted postoperatively for IV antibiotics, IV pain control and physical therapy. Postoperatively, the patient had poor glycemic control as well as elevated creatinine. The patient’s hospital stay was six days. Throughout the hospitalization, the patient continued to require IV pain medication for pain control as well as medication adjustment for blood glucose, electrolyte abnormalities and tighter blood pressure control.

At one point, the patient’s hemoglobin was 7.3 g, however the patient refused transfusion. Prior to discharge, the patient’s blood pressure was better controlled as well as her blood glucose and electrolytes. She was accepted into a skilled nursing facility upon discharge.

DENIED INPATIENT STAY

The six-day “acute inpatient hospital admission” was denied by the insurance company based on Medicare and health plan criteria which called for severe symptoms and services that can only be provided in an inpatient setting. The insurance company initially determined that the criteria had not been met due to the following rationale: “no available documentation of an insufficient response to treatment, need for intervention or presence of a condition not likely to improve in a lower level of care.” The insurance company stated that there were no abnormal lab or diagnostic findings such as hemodynamic instability, respiratory distress or surgical complications that required an inpatient level of care.

PEER-TO-PEER DISCUSSION

An AppriseMD physician advisor conducted a Peer-to-Peer discussion with the insurance company’s medical director for this case. As a result of the conversation and a review of the case, the medical director agreed with inpatient level of care for this patient admitted with a complex trimalleolar ankle fracture. The patient’s complex medical history including metastatic ovarian carcinoma undergoing current chemotherapy and the urgent surgical intervention needed for her injury as well as post operative episodes of hypoglycemia and AKI justified the inpatient level of care, and the denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Alcohol Withdrawal

One day after being released from the hospital for alcoholic intoxication and suicidal ideation, a 53-year-old male arrived in the Emergency Department with alcohol withdrawal with seizures and hyponatremia. The patient had a history of alcohol abuse and multiple admissions for withdrawal, diabetes along with a left foot cellulitis diabetic wound, hypertension, anxiety, and depression. The patient was transported to the hospital after a four-minute seizure during which he fell and bit his tongue. He confirmed that he had not been taking his seizure medication and reported drinking heavily – 2-3 cases of beer per day. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was determined to be 16.

The patient continued treatment on the second day in the hospital with continued Haldol as well as fall precautions, seizure precautions and telemetry monitoring. The patient left the hospital on day 3 against medical advice.

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DENIED INPATIENT STAY

The inpatient stay was surprisingly denied by the insurance company because hospital records showed that the patient presented with “whole body shaking” but did not show continued bleeding, bad liver problems, low blood pressure, problems with blood clotting, any need for urgent surgery or kidney or heart problems. The insurance company stated that based on the records presented and using national guidelines, the admission was an observation stay.

PEER-TO-PEER DISCUSSION

A Peer-to-Peer discussion was completed between AppriseMD and an insurance company physician 10 days after the hospital stay. The insurance company doctor reversed the denial and approved the inpatient stay agreeing, upon further discussion, that the patient was admitted for ETOH withdrawal and hyponatremia. The patient also experienced problems when sodium levels corrected too quickly. The inpatient stay was needed for DDAVP treatment to slow down the correction. Given the patient’s continued elevated CIWA, inpatient care was approved despite the fact that the patient left AMA.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Alcohol Withdrawal + COVID-19

A 19-year-old patient arrived in the emergency room with alcohol withdrawal symptoms and subsequently tested positive for COVID-19. The patient had a past medical history that included anxiety, depression, alcohol withdrawal seizures, hallucinations, alcohol abuse and dependence, and hypertension. He reported passive suicidal ideations without a plan. The patient, who reportedly drank about a liter of whiskey a day, was seeking an alcohol detox program and had a history of delirium tremens. Lab results showed an ETHO breath test of 0.138 and Clinical Institute Withdrawal Assessment (CIWA) 3-23 with additional lab results that showed the following: sodium 134, potassium 4.1, creatinine 0.74, magnesium 2.1, ALT 205, AST 147, total bili 0.8, lipase 160, white count 4.2, hemoglobin 17.4, and platelets 181. Urine drug screen was negative. The patient was treated with the CIWA protocol (Serax tapering dose of benzodiazepine) and also received Haldol.

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DENIED INPATIENT STAY

The insurance company initially denied the inpatient stay saying the services could have been provided in an observation (outpatient) setting. The denial stated that records did show that medications and fluids were given by vein but that there was no bleeding, liver problems, low blood pressure, clotting, need for surgery and no kidney or heart problems.

PEER-TO-PEER DISCUSSION

A peer-to-peer discussion was completed between AppriseMD and the insurance company’s doctor regarding this case and the denial was rescinded. An inpatient level of care was approved. The discussion centered around the 19-year-old patient’s history of acute alcohol withdrawal, passive suicidal ideation and the incidental COVID positive test. AppriseMD showed that the significant ETOH withdrawal symptoms and agitation required Haldol, IV and PO Ativan and Serax and supportive care. Upon further review, the insurance company agreed and overturned the denial.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Multiple Sclerosis

A 79-year-old female with a history of multiple sclerosis, hypertension, motion sickness, neuropathy, osteoporosis, renal insufficiency, UTIs arrived at the hospital feeling weakness in her lower extremities after a fall at home. She notably had received a COVID booster shot on the same day that she developed weakness and was unable to walk on her own. The patient was admitted and received a neurology consult for evaluation of what treating physicians thought could be a possible MS flare up. An MRI of the brain, cervical, and thoracic spine showed no active lesions except for a questionable enhancing small lesion posterior to the C7 vertebral body. All labs were normal, and the patient resumed her home medication regimen.

On the following day, the patient’s lower extremity weakness improved. Neurology obtained a carotid ultrasound to rule out all possible causes and found no significant carotid artery stenosis that may have contributed to her acute presentation. The patient received physical therapy and was able to ambulate around the room with no weakness in the extremities. Patient was discharged on the second hospital day to continue with her routine medications.

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DENIED INPATIENT STAY

The insurance company denied the inpatient stay based on the fact that criteria was not met for an inpatient admission. The reason given was “no documentation of an insufficient response to treatment, need for intervention, or presence of a condition not likely to improve in a lower level of care.” The patient’s lab results did not show any abnormal or diagnostic finding and there were no specialized services received that could not have been provided in a lower level of care. Finally, there was no persistent hemodynamic instability, severe altered mental status, or neurological deficit found.

For those reasons, the inpatient hospital admission was denied.

PEER-TO-PEER DISCUSSION

AppriseMD reviewed this case on hospital day one as a live case review. With imaging pending and potential plans for further pharmacologic interventions, the AppriseMD physician recommended inpatient level of care at the time.

At AppriseMD we hold ourselves accountable when denied inpatient stays are upheld and we agree with the decision. AppriseMD will let the hospital know our further recommendation of whether or not it is worth the hospital’s effort to attempt an appeal. In this case, because the AppriseMD physician agreed with the upheld decision of the insurance company, we would advise against an attempt at an appeal.

Reviewing this case in retrospect, the AppriseMD physician agreed that the care provided could have been at a lower level of care.

OUTCOME: DENIAL UPHELD

CLINICAL SUMMARY: Unstable Angina TIMI 3

A 67-year-old male arrived in the Emergency Room complaining of chest pain located at the center of the chest radiating to the left shoulder and neck. The patient felt a sensation of pressure and had shortness of breath. The patient had a past medical history of diabetes, hypertension, hyperlipidemia, OSA and had undergone a lumbar spine fusion. The patient also had abnormal results from a recent stress test and was scheduled for a cardiac angiogram. ER physicians administered nitroglycerin which relieved the pain.

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Clinical Summary continued:

In the emergency room, an EKG was ordered, and a cardiologist was consulted.

The patient’s vital signs were:

Blood pressure 117/61-153/76
Heart rate of 75-85
Respiratory rate 13-20
Temperature of 97.9 F
Oxygen saturation of 87-96% on room air

Labs were:

WBC 6.41
Hb 12.7
Na 136
K 4.1
Bun 15
Cr 1.0
Troponin <0.06 x2
Glucose 382
CXR with no acute process
EKG with no acute changes, sinus rhythm, atrial premature complex, left anterior fascicular block
PE: A03, NAD
CVS: RRR, Normal S1 and S2, no murmur
Lungs: CTAB, no use of accessory muscles, no intercostal muscle retractions, no wheezing

DENIED INPATIENT STAY

The patient was admitted to the hospital with a diagnosis of unstable angina (TIMI 3) made by both the hospitalist and cardiologist. The inpatient admission was denied by the insurance company because “medical necessity criteria were not met based upon MCG.” However, on the second day in the hospital, due to the ongoing symptoms and the abnormal stress test, the decision was made to proceed with coronary angiography. Doctors performed the angiogram and found critical stenosis of the RCA as well a 60-70% stenosis of the left main. Because of the critical stenosis of the RCA, the patient underwent angioplasty and had a drug eluting stent placed. The procedure was successfully performed without complication and the left femoral artery was closed with Angio-Seal. On the day of discharge, the patient continued to have some chest pain, which was resolved with medication adjustment and monitoring. Despite this treatment, the insurance company said, “no situations suggest procedures that might otherwise be performed on an ambulatory basis required inpatient care or postoperative events or clinical findings.”

PEER-TO-PEER DISCUSSION

The insurance company noted in its initial denial of the inpatient stay that a “review with updated clinicals might be of benefit if member develops complications or has need for hospitalization beyond 48 hours.” Considering the patient’s history, condition on presentation and procedures performed as well as the patient’s ongoing chest pain, a Peer-to-Peer was conducted by AppriseMD with the insurance company medical director to discuss the case. AppriseMD demonstrated that the patient was not ready to transfer to a lower level of care and remained in the hospital for an additional day. The total length of stay was two days for this patient. The denial was successfully overturned, and inpatient level of care was approved.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Chest Pain, Non-Cardiac

A 54-year-old male patient arrived in the emergency room with left-sided chest pain and left neck pain that had been occurring all day and intermittently for the previous 6 months. He rated the severity of pain at the time as an 8/10. The patient reported feeling short of breath on exertion with nausea, vomiting, dizziness, and weakness. The patient denied melena, fever, hearing loss, leg swelling, dysuria, gait problems, pallor headache or confusion. He took an aspirin twice on the day of admission. The patient had a history of hypertension, dyslipidemia, asthma, arrhythmia and underwent an incomplete stress test in the previous year. He also reported having 1-2 drinks daily and was vaccinated for COVID.

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Clinical Summary continued:

In the emergency room, an EKG was ordered as well as laboratory testing, echo, a chest X-Ray, IV fluids, a beta blocker, Zofran, aspirin, and morphine. The patient’s vital signs were:

Blood pressure 110/160 – 152/96
Heart rate of 57-93
Respiratory rate 13-17
Temperature of 97.9-98.2 F
Oxygen saturation of 94-97% on room air

Labs were:

DENIED INPATIENT STAY

On hospital day 2 the patient’s pain was resolved but inpatient care was considered appropriate due to the ongoing cardiac workup. The patient was on a nitro drip and underwent a coronary angiogram. Although there was no evidence of severe coronary artery disease, the patient continued to require hospital level of care for medical management and further evaluation. However, the insurance company denied the inpatient stay stating that records did not show:

The insurance company stated the stay was more appropriate for observation.

PEER-TO-PEER DISCUSSION

After the initial denial by the insurance company, a robust Peer-to-Peer discussion was held between AppriseMD and the insurance company’s medical director. The patient’s cardiac testing was essentially normal, the symptoms resolved, and the chest pain was determined to be non-cardiac in nature. However, the denial was overturned based on the following:

This was believed to be unstable angina on admission.
There was intensive emergent therapy including a nitroglycerin drip.
There was need for invasive diagnostic evaluation (cardiac catherization).

Chest pain cases that are found to be due to causes other than frank ACS can often be difficult for inpatient level of care approval. We believe that these cases often involve significant hospital resources as well as significant treating physician concern. Clear and honest discussions about the admitting clinicians’ concerns, plan of care, and resources used can help get to the most appropriate level of care.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Bilateral Pneumonia

A 23-year-old nonverbal female patient arrived in the emergency department with her parents who said she had a fever and heavy breathing since the morning. The patient’s medical history included Lennox-Gastaut Syndrome, severe mental retardation, seizure disorder, recurrent aspirations, recurrent pneumonia and vagal nerve stimulator. Her parents said she had been suffering with flu-like symptoms for the previous week. However, she had no cough, vomiting or abdominal pain. It is noted that the patient was not physically able to cough. She had been vaccinated for COVID-19 and received a booster as well as the influenza vaccine.

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Clinical Summary continued:

Her vital signs were as follows: VS: T max 102.8, pulse 106-141, respiratory rate 20-41, blood pressure 87/41-107/52, Oxygen saturation 95% room air. Bilateral crackles on lung exam. Labs: WBC 12.87, Hgb 13.0, platelets 366, Na 139, K 3.6, BUN 12, Cr 0.64, glucose 102, lactate 1.9, CRP 61.8, BC x2: NG, Respiratory Filmarray: COVID-19: negative, Parainfluenza Virus 4: + IMAGING: CXR: Bilateral interstitial opacities are suspicious for infection.

IV fluids and Tylenol were administered in the ED with no significant improvement in her status, so the patient was admitted and started on IV antibiotics for sepsis due to bilateral pneumonia. She had a PSI score of 43, Class II (criteria met: 23 y/o, Female, respiratory rate >30, Heart rate >125).

By the next day in the hospital, the patient’s fevers resolved, and her lungs were clear to auscultation bilaterally upon examination. The family said the patient was at her baseline. They asked for the patient to be sent home if possible. After consultation from infectious disease, the patient was cleared for discharge on oral antibiotics.

DENIED INPATIENT STAY

The short hospital stay was denied by the insurance company because, according to the insurance company, the stay did not meet the guidelines required for an inpatient stay. The denial notes stated that the reason for the admission was pneumonia but the patient “did not have to be admitted as an inpatient in the hospital for this care.” The insurance company also stated that the patient did not have severe illness, was stable and “had test that did not show any problems that needed inpatient only treatment.” The insurance company argued that the patient could have received the care needed without being admitted as inpatient to the hospital as the patient did not need oxygen or pain medicine through an IV.

PEER-TO-PEER DISCUSSION

Despite a very quick improvement and discharge the following day, the hospital felt that an inpatient stay was warranted based on the patient’s complex history and condition at presentation. A peer-to-peer discussion was requested with the insurance company. Discussing the complexity of this patient’s presentation helped overturn the denial. The P2P was completed between an AppriseMD physician and the insurance company medical director. After a discussion, the insurance medical director agreed with inpatient level of care for this high-risk patient admitted with bilateral pneumonia with evidence of sepsis. Although the patient improved and was discharged the next day, inpatient level of care was supported, and the inpatient denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Diabetes

This case study involves a 54-year-old female patient with a past medical history of type I diabetes, diabetic gastroparesis, nephrolithiasis, hypothyroidism, hypertension, and traumatic brain injury. She arrived in the ER out of concern for diabetic ketoacidosis (DKA). The patient was hospitalized for DKA one month before this admission. She had been sick with nausea, vomiting, upper abdominal pain similar to prior gastroparesis attacks and was unable to take her insulin for several days. On the day of admission, she started noting blood sugars greater than 400 on her monitor at home, as well as a very dry mouth, and the inability to stay hydrated. The patient had no fever, chest pain, shortness of breath, or cough. In the ER, there was generalized abdominal tenderness and tenderness in the right upper quadrant and epigastric area. There was no rCVA tenderness, guarding or rebound. Her vital signs were as follows: temperature max 100 degrees F, pulse 102-126, respiratory rate 16-20, blood pressure 112/63, oxygen saturation 100% on room air. A chest x-ray was unremarkable. Her labs had the following results: WBC 14.54, Hgb 15.3, platelets 494, Na 128 (135 corrected for glucose 464), K 5.2, CO2 11, BUN 21, Cr 1.32, osmolality 289, VBG pH 7.11, β-OH butyrate 91.30, Glucose 76-493. Urine analysis: + glucose, + ketones.

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DENIED INPATIENT STAY

The patient was admitted to the ICU, started on IV fluids and an insulin drip and an order for electrolyte replacement as needed. The patient responded well, and the insulin drip was discontinued by hospital day two once DKA resolved and her home long-acting insulin resumed. The patient felt significantly better the following day and left the hospital against medical advice (AMA).

PEER-TO-PEER DISCUSSION

After the inpatient admission was denied, there was a P2P completed between AppriseMD and the insurance company doctor regarding the case. Although this case met the insurance company’s short stay policy for observation care, the low arterial or venous pH (7.11) and the patient leaving AMA were compelling . After a robust discussion, the insurance company doctor agreed with inpatient level of care for this patient care and overturned the inpatient denial.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: COPD

This case involved an 83-year-old female patient with a known history of chronic COPD on 4L supplemental oxygen via nasal cannula, DVT, gout, multiple falls, hypertension, and anxiety. She arrived in the emergency department with complaints of shortness of breath that had gotten worse over the previous 24 to 48 hours, especially on exertion. She said she was out of breath earlier in the day with self-measured oxygen saturation in the low 70’s. She increased her oxygen to 5L without significant improvement. She did not have a cough, fever, chills, nausea, or any vomiting. Patient also reported intermittent chest pain under the left breast that felt like ‘something catches’ and was impacting her breathing.

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DENIED INPATIENT STAY

The patient underwent extensive evaluation including EKG, Troponin levels and chest X-ray -- all were unremarkable. The CT angiography of the chest showed a 2-cm adrenal adenoma and work-up with CBC showed a leukocytosis. There was a possible lipoma under left anterior chest that may have been causing her reproducible chest discomfort. The patient was diagnosed with acute hypoxic respiratory failure with acute exacerbation of COPD and was treated with increased supplemental oxygen to keep saturation above 89%, bronchodilator therapy and prednisone.

The patient improved her breathing and was back at baseline supplemental oxygen by hospital day two. She was able to ambulate and maintain an oxygen saturation above 90% on her baseline 4L supplemental oxygen. She recently had pulmonary function testing done and had established care with a primary care physician as well as a visiting home nurse and physical and occupational therapy. She was discharged on oral prednisone on hospital day four.

PEER-TO-PEER DISCUSSION

The above case was denied by the insurance company, which stated the patient did not show signs/or symptoms severe enough to need services that can only be provided safely and effectively on an inpatient basis. The insurance company also cited no acute respiratory failure, no new-onset hypoxemia that persisted despite observation care treatment, altered mental status, high-risk active acute comorbidity and no signs of chronic COPD that persisted beyond observation care treatment as reason for the denial. In addition, the denial stated there was also no documentation of planned invasive procedures or invasive monitoring.

An AppriseMD physician conducted a P2P with the insurance medical director arguing the need for inpatient level of care services for this elderly patient with a significant past medical history, acute hypoxic respiratory failure with acute exacerbation of COPD who required supplemental oxygen and therapies during her stay as well as extensive work-up for chest pain. This patient’s work-up and treatments required several days of hospital level care. The insurance medical director eventually agreed to inpatient level of care for this patient. The denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Sepsis

This case involved a 74-year-old patient who presented with chills and a temperature of 103°F. The patient had a past history of hypertension, arthritis, and right total shoulder replacement in January 2021. Chest x-ray showed coarse perihilar and interstitial markings, likely viral or reactive. A CTA chest was negative for pulmonary embolism or acute pulmonary disease. A urine test was nitrate positive with trace leukocyte esterase. Blood cultures were drawn, and urine was sent for culture.

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DENIED INPATIENT STAY

The patient began a course of ceftriaxone and fluid resuscitated and was admitted for further management. During the three-day hospitalization, the urine culture came back growing gram-negative rods but the patient's heart rate, temperature, and BP normalized. The patient worked with physical therapy and was transitioned to oral antibiotics and was stable for discharge after the third day. The insurance provider stated in a denial letter that coverage for an “acute admission” was denied because “medical necessity criteria were not met based upon MCG.” It stated the rationale for the decision was no IV vasopressors required, improved BP on day two as well as no repeated IV fluid, no AMS, no AKI and no urinary system finding required invasive procedures.

PEER-TO-PEER DISCUSSION

The patient was admitted for sepsis from a UTI and a P2P discussion between AppriseMD and the insurance company followed the initial denial. The denial was challenging to overturn, but after a lengthy discussion on the patient’s high BMI (>50), recent shoulder surgery, and three-day length of stay, the case was approved for an inpatient stay. The denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: NSTEMI

This case centers around a 59-year-old female who arrived at the hospital ER with ‘tightness’ and left-sided chest pain that began at rest. The patient said she has had similar pain several times over the last month. She suddenly awoke with severe left lower quadrant pain, which is a chronic issue for her IBS/colitis, that night. Shortly after her abdominal pain started, she reports left-sided chest discomfort with associated nausea. She said she has a large amount of stress at home.

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DENIED INPATIENT STAY

The patient was admitted for ischemic evaluation. With troponins up-trending and nonspecific EKG findings, a TTE showed motion wall abnormalities as well as systolic dysfunction. Cardiac catherization showed ejection fraction of 35% and no evidence of coronary artery disease. The patient was treated with heparin drip and was medically managed. The patient was diagnosed with Takotsubo cardiomyopathy. Her stay was complicated by relative hypotension the day after admission. The inpatient stay was denied by a managed Medicare payer.

PEER-TO-PEER DISCUSSION

P2P completed between AppriseMD and Aetna just a few days after the hospital stay was denied. AppriseMD’s Case Review Physician said this case “was not an easy one,” stating that the insurance company wanted to deny due to patient improving within 48 hours. However, AppriseMD argued that this was an NSTEMI with intensive workup and management needed. The denial was overturned, and inpatient was approved.

The patient improved quickly (in less than 48 hours) thanks, in part, to the great medical staff but that does not lessen the resources and intensity of care rendered for the patient.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Suicidal Ideation

A 47-year-old patient was admitted for an intentional drug overdose, suicidal ideation, anxiety depression and alcohol abuse. Past medical history showed the patient suffered from bipolar disorder, anxiety depression panic attacks. The ER report stated the patient arrived via EMS after taking one bottle of benzodiazepines along with alcohol but was alert. The patient was admitted to a step-down unit with 1-on-1 sitter for suicidal and seizure precautions.

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DENIED INPATIENT STAY

The insurance denial for the hospital was based on a diagnosis of hypokalemia, suicide ideation, electrocardiogram and poisoning by drugs but did not show the need for care at a higher level based on Centene Short Inpatient Hospital stay Clinical Policy.

PEER-TO-PEER DISCUSSION

After reviewing the case for a hospital client, AppriseMD determined the case was a valid suicide attempt based on available documentation and was worth a P2P attempt to reverse the denial.

A Peer-to-Peer discussion was completed. The payor initially upheld the denial, but AppriseMD’s Case Review Physician was able to finally overturn based on the continued mild hypokalemia with long QTC and the need for continued 1:1 sitter. This is an example of how a calm and professional P2P can lead to the appropriate level of care.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Post C-section

A 36-year-old new mother with a recent C-section was admitted after an ER visit due to shortness of breath occurring since the delivery of her child and drainage from her surgical incision. The patient had a significant past medical history of morbid obesity, asthma, and sleep apnea. The physician summary showed the patient had acute toxic respiratory failure due to asthma exacerbation.

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DENIED INPATIENT STAY

Aetna denied the hospital stay citing the information sent by the hospital did not show the need for extra oxygen or breathing treatments for more than 24 hours nor did it show problems with blood pressure or heartbeat.

PEER-TO-PEER DISCUSSION

A Peer-to-Peer was completed between an AppriseMD physician on behalf of the hospital and Aetna. The case was reviewed in detail. The AppriseMD physician communicated that the patient needed IV steroids and IV antibiotics. The case was overturned based on the patient’s high BMI (74) and active steroids which was a setup for antibiotic failure and a poor clinical outcome.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Acute Diverticulitis

A 69-year-old female with past medical history of atrial fibrillation, aortic/mitral valve replacement, chronic anticoagulation, hypertension, hyperlipidemia, diabetes mellitus, neuropathy, GERD, COPD. The patient was admitted to the hospital with chief complaint of abdominal pain and bright red blood per rectum. The CT of the abdomen pelvis showed diffuse colonic bowel wall thickening compatible with colitis/diverticulitis.

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DENIED INPATIENT STAY

The inpatient stay was denied based on the patient not meeting health plan criteria for an inpatient stay. The patient medical records showed she was admitted with non-infective gastroenteritis and concern for ischemic colitis. The denial said that the chart showed no available documentation of an insufficient response to treatment, need for intervention or condition not likely to improve with a lower level of care.

PEER-TO-PEER DISCUSSION

AppriseMD completed a P2P with the insurance company regarding the patient. The doctor with the insurance company agreed with the inpatient level of care for this patient with acute diverticulitis with a significant concern for ischemic colitis. The patient had persistent pain for several days and required care beyond the observation timeframe and the inpatient denial was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Cardiac Ablation

A 79-year-old patient was scheduled to have an elective cardiac ablation which went well, but the patient developed hypotension post procedure. In a previous ablation procedure, the patient had a similar response post ablation with hypotension requiring several days of hospitalization. The most recent hypotension required Levophed. The patient was also diagnosed with a UTI prior to the ablation and antibiotics were on-going.

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DENIED INPATIENT STAY

The insurance carrier – UnitedHealthcare– said in its denial that it based the decision on “health plan and Medicare criteria that say a member must show signs and/or symptoms severe enough to need services that can only be provided safely and effectively on an inpatient basis.” The statement said that criteria had not been met citing 10 different conditions that did not apply to the patient including heart failure, urgent cardioversion and medication toxicity.

PEER-TO-PEER DISCUSSION

A P2P discussion was completed by an AppriseMD case review physician and the UHC medical director regarding the above patient. After the discussion, the UHC medical director agreed with inpatient level of care for this patient who underwent a scheduled cardiac ablation that was complicated by post-procedure severe hypotension necessitating ICU care including treatment with Levophed. Inpatient denial overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Short Stay Policy

Patient was admitted to the hospital for orbital cellulitis IV treatment. The patient presented with left eye redness and pain with movement, especially over the left gaze. There was no history of recent trauma. Maxillofacial CT showed mild left globe proptosis with preseptal edema, mild rectus enlargement with possible surrounding fatty stranding. As per ophthalmology patient was thought to have possible orbital cellulitis and placed on broad-spectrum IV antibiotic therapy. The patient, who also had a history of drug abuse, decided to leave against medical advice while being treated.

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DENIED INPATIENT STAY

The inpatient short stay was denied for this patient due to the “Centene Short Inpatient Hospital Stay Clinical Policy” according to the insurance denial letter. The denial said the patient notes did not show “a procedure that needed a hospital stay … care at a higher-level unit … unexpected death” among other notes.

PEER-TO-PEER DISCUSSION

P2P completed between AppriseMD and medical director of Meridian. The discussion resulted in the denial being rescinded and inpatient approved. The P2P showed the patient was admitted with orbital cellulitis involving his medial rectus muscle. He was treated with IV antibiotics and ID (infectious disease) consultation. The patient left AMA the day after admission though he was advised to remain for continued IV antibiotics. The provider overturned the denial and approved the inpatient short stay due to orbital cellulitis and an exception to Meridian's short stay policy due to leaving AMA.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: TIMI Score

An 80-year-old patient with a past medical history of atrial fibrillation, arthritis, congestive heart failure, COPD, hyperlipidemia, hypertension, history of PE, pacemaker GERD, arrived in the Emergency Department with chest pain which had been occurring for a week.

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DENIED INPATIENT STAY

The attending physician who treated this patient saw distress and presenting symptoms, which also included a recent fall, and decided upon inpatient level of care as the best and safest course of action. The patient was diagnosed with unstable angina and AKI.

PEER-TO-PEER DISCUSSION

A P2P for this case was completed between AppriseMD and medical director of Humana. This patient was admitted for unstable angina and AKI. While Troponins were negative and patient got no intervention, the attending physician did treat medically and started Ranexa (anti-anginal medication). AKI slowly improved with holding ACE inhibitor (medication). Due to the high risk of patient with elevated TIMI score, the case was overturned.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Hemodialysis

A 48-year-old male patient was admitted for fluid overload with symptoms of shortness of breath and weakness due to missing hemodialysis appointments. The patient had a significant past medical history of hypertension, dyslipidemia, atrial fibrillation, end-stage renal disease and was on hemodialysis three times a week. When admitted, the patient was also complaining of a recurrent abscess in the mouth previously drained but not treated due to a missed follow-up. The patient was admitted for incision and drainage of the abscess and IV antibiotics.

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DENIED INPATIENT STAY

Insurance denied this inpatient stay because the main diagnosis was volume overload from ESRD (end-stage renal disease) and missed hemodialysis. In the denial, the insurance provider said the patient notes did not show “a procedure that needed a hospital stay” and suggested “end of life care instead of getting care at the hospital” citing “Centene Short Inpatient Hospital Stay Clinical Policy.”

PEER-TO-PEER DISCUSSION

It took an AppriseMD physician advisor to argue the medical necessity of hospitalization for his recurrent oral abscess and the medical resources (I&D procedure, IV antibiotics, monitoring) used at the inpatient level of care. AppriseMD conducted a Peer-to-Peer with the insurance medical director regarding the patient which resulted in the denial being rescinded and inpatient approved. Patient was originally admitted due to fluid overload due to missed dialysis.

The patient was initially in observation status until he was made inpatient due to hard palette abscess that required surgical I&D and IV antibiotics for several additional days. The patient also needed outpatient dialysis center to be set up. Finally, the hospital course was complicated by a period of altered mental status as well.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Oropharyngeal Cancer and Alcohol Withdrawal

Patient with SCC oropharyngeal cancer was admitted to the hospital with alcohol withdrawal. No beds were available at a detox center; therefore, the patient was brought to the Emergency Department for help.

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DENIED INPATIENT STAY

This patient was admitted for alcohol withdrawal, but the inpatient stay was denied by Aetna due to the following reasons, “The records sent by the hospital show that you went to the hospital. You have an alcohol use disorder. You had tests done. You were given medications by vein. You were given fluids by vein. ….the records do not show that you had a lot of new bleeding, had bad liver problems, had low blood pressure and did not pass out,” the denial went on to say the patient showed no problems with blog clotting or need of surgery nor did it show kidney or heart problems. Based on that information the inpatient level of care was denied and changed to observation services.

PEER-TO-PEER DISCUSSION

A P2P between AppriseMD and the insurance company provided a more complete picture of the patient’s condition. The patient was admitted for alcohol withdrawal but was medically complex with active SCC oropharyngeal cancer. The patient was brought to the Emergency Department because there were no beds available in the detox center. In addition, the patient missed several oncology appointments due to the re-emerging alcohol dependence. The patient’s history showed he had not had withdrawal episode since 2014, but the recent cancer and treatment caused him to restart drinking.

AppriseMD’s Case Review Physician felt the inpatient level of care was warranted given the patient’s illness and the fact that he was given Ativan and a Serax taper and was being monitored for hyponatremia. The CRP explained in the P2P that this was the only care plan that would safely allow treatment of alcoholism allowing for the underlying cancer treatment. On Hospital Day 4, the patient had continued tachycardia up to 103. The extended length of stay and continued symptoms allowed for an overturn despite oral medications. Considering the patient’s chronic disease, comorbidities, etc. helped overturn the denial. Being admitted was the only safe plan for the patient without rehab availability.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Asthma and High BMI

Patient with a history of asthma and a high BMI was admitted with asthma exacerbation and a wound infection.

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DENIED INPATIENT STAY

The hospital asked for an inpatient admission stay for the patient, which was denied by Aetna which said the records sent by the hospital do not show the need for the extra level of care including oxygen or breathing treatments for over 24-hours nor did it show problems with blood pressure, heart issues or other problems triggered by the asthma or infection in the blood stream. It was deemed an observation stay.

PEER-TO-PEER DISCUSSION

AppriseMD conducted a Peer-to-Peer review of this case during which it shared patient history with the insurer including a history of high BMI and the fact that the patient was on steroids, which increases the risk of antibiotic failure. AppriseMD clinical team was able to provide more insight into this patient’s elevated risk and through the P2P process was able to overturn the inpatient denial.

OUTCOME: DENIAL OVERTURNED

CLINICAL SUMMARY: Total hip arthroplasty

A 66 year-old patient undergoing total hip arthroplasty. The patient received an ASA score of 3, having multiple comorbidities including asthma and need for postoperative supplemental oxygen therapy.

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DENIED INPATIENT STAY

A scheduled arthroplasty was denied by a commercially managed Medicare insurance company based on the evidence that the patient’s signs and/or symptoms were not severe enough to need services that could only be provided safely and effectively on an inpatient basis. The recommendation was this patient’s total hip arthroplasty could have been safely done in an outpatient setting.

PEER-TO-PEER DISCUSSION

Our physician reviewer argued that given this patient’s ASA score of 3, multiple comorbidities including asthma and need for postoperative supplemental oxygen therapy warranted inpatient level of care for his total hip arthroplasty. Despite moves to outpatient status, AppriseMD believes that most total hip arthroplasties should be inpatient.

OUTCOME: DENIAL OVERTURNED

The denial was overturned by the insurance company. The patient righteously was covered for the inpatient medical and supportive care he needed and the hospital was covered for the resources utilized to provide the utmost care for this patient.

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Can Peer-to-Peer reviews overturn short hospital stay in-patient denials? We have done a limited study and seen the benefit of P2P reviews at AppriseMD and how it can reverse denials and recoup dollars for hospitals.

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CASE STUDIES

Difficult inpatient-stay denials

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CLINICAL SUMMARY: One-day inpatient denial overturned

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CLINICAL SUMMARY: Alcohol Withdrawal

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