Patients admitted to the hospital with chest pain and other significant findings in the ER can still be denied for inpatient stay by insurance companies. One case involving a patient with severe stenosis of the right coronary artery and another critical lesion shows how an initial denial by the insurance company can be overturned after a Peer-to-Peer discussion reveals the intricacies of the case.
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.
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
- 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.”
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