An inpatient level of care (LOC), initially denied by a Medicare Advantage payer, was approved after a peer-to-peer discussion involving a stable patient with a complex medical history and condition that required a transfer to a higher LOC. The short stay exemplifies the importance of having physicians with both payer and clinical experience facilitate the peer-to-peers to ensure that denials are overturned.
CLINICAL SUMMARY:
A 79-year-old Medicare Advantage (MA) patient with an implantable cardioverter defibrillator (ICD) initially in place for 18 years arrived at the Emergency Department (ED) with pain at the ICD pocket site and an open wound developing on the pocket. His cardiologist encouraged him to visit the ED for evaluation and treatment. Doctors noted externalization/pocket erosion of the ICD and infection. The patient’s significant medical history included arthritis, atrial fibrillation, benign prostatic hyperplasia, coronary artery disease, congestive heart failure, gastroesophageal reflux disease, hyperlipidemia, hypertension and thrombosis. Additionally, the patient had a heart catheterization earlier in the year that resulted in two stents placed, a previous ICD pocket revision and received chronic anticoagulation medication.
Upon arrival in the ED, the patient did not have any fever, chills, cough, congestion, shortness of breath, chest pain, abdominal pain, nausea or vomiting. When admitted, the patient was essentially hemodynamically stable, and labs revealed lactic acidosis (2.0 >1.1) but did not show leukocytosis or any other abnormalities. Additional labs and vitals were as follows: 98.6, HR 70-74, RR 16-18, BP 119/79-155/96, 90-96% O2 RA, WBC 7.23, Hgb 15, Na 140, K 3.8, BUN 26, Cr 1.02, Glu 14.
Doctors admitted the patient for inpatient care to address the ICD malfunction, pocket hematoma, wound dehiscence and cellulitis. An EKG showed no acute ischemia or cardiac dysrhythmia. Admission for further evaluation was deemed appropriate following consults by both cardiology and infectious disease physicians. The hospital where the patient had previously undergone ICD repositioning was also consulted. The treating physicians followed blood cultures obtained on admission and recommended ICD extraction with continued empiric vancomycin and cefazolin for the infection. The patient was transferred to a higher level of care (LOC) at another hospital for extraction.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe MA plan denied the inpatient LOC for the patient’s hospital stay prior to his transfer. The denial referenced a thorough review of the case and the patient’s complex medical conditions, also factoring in appropriate coverage and benefit criteria. The payer also reviewed whether the services were reasonable and necessary, and inpatient LOC was denied.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor completed a peer-to-peer discussion with the payer’s medical director regarding the case. The discussion included the patient’s extensive medical history and reoccurring ICD issues stemming from the initial insertion in 2007. A discussion about the patient’s hospital stay involving his second pocket externalization and pocket erosion ensued. The physician advisor reminded the payer that doctors started the patient on IV vancomycin, IV Ancef and a heparin infusion. On hospital day two, treatment continued with ongoing IV antibiotics, and the infectious disease consultation recommended ICD extraction.
The patient was ultimately transferred to a higher LOC, where the original placement was performed. Given the risk of device-related sepsis, recurrent pocket erosion, and the patient’s multiple comorbidities requiring continuous IV antibiotics and coordination of extraction at a higher-level facility, inpatient status was not only reasonable but critical for safe and effective care. This case illustrates the clinical appropriateness of inpatient care for an elderly patient with a recurrent ICD pocket infection, whose treatment required intravenous antibiotics and transfer to a higher LOC for surgical extraction.