Peer To Peer Review for Hospital Cases

Case Study: Acute diverticulitis stay denied

Healthcare insurance companies often deny inpatient hospital stays if the information provided does not show intensity of services significant enough to need inpatient care. If the patient’s care is more intense than the medical record implies a Peer-to-Peer discussion can provide more critical information to the insurance company.

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.


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
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