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 diabetes, and essential hypertension.
The patient’s labs showed a potassium level of 3.2, glucose of 214, and albumin of 3.5. A chest CT was ordered, showing right lower lobe consolidation, suspicious for pneumonia. No pulmonary embolism was evident. There was also a right hilar lymphadenopathy. An EKG showed A-fib with a heart rate of 133 bpm, left bundle branch block, and QTc of 511 ms. This patient had a recent echocardiogram with an EF of 55-60% with mild mitral regurgitation (MR) and tricuspid regurgitation (TR). The patient was admitted for pneumonia and A-fib with rapid ventricular response (RVR).
The patient began an IV amiodarone bolus and an IV infusion along with an IV cefepime, and vancomycin. Cardiology was consulted and given the need for continuous medical care requiring IV medications, the attending physician expected the patient would require more than two midnights of hospital-level care.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe Medicare Advantage (MA) plan denied the hospital stay, stating that the medical record did not meet inpatient level of care (LOC) criteria with no persistent hemodynamic instability documented.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSWhen this stay was denied by the MA plan, the hospital referred this case back to AppriseMD for a peer-to-peer (P2P) payer review. The AppriseMD physician advisor spoke with the MA plan medical director and discussed this patient’s history of ovarian cancer (now in remission), CHF with a recovered ejection fraction (most recent echo with EF 55-60%), and paroxysmal A-fib who presented with palpitations and cough with shortness of breath. The physician advisor reiterated that the patient was found to have A-fib with RVR as well as pneumonia and began an amiodarone infusion and broad-spectrum IV antibiotics. By the second hospital day, the patient had improved hemodynamics, conversion to normal sinus rhythm, and lacked evidence of decompensated heart failure. This was a challenging case that AppriseMD was able to overturn by arguing that this was a complex and high-risk pneumonia patient. After a lengthy P2P review with the medical director, inpatient LOC was approved for this patient.