A brief denial letter with limited explanation for a complicated case should not be the end of the road for a hospital claim. A recent three-day hospital stay for a patient with a history of breast cancer who underwent a left mastectomy and experienced severe postop complications was denied by the insurance company but then reversed after a Peer-to-Peer discussion to delve into the details of the case.
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.
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.
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.