Inpatient denials for elderly patients on Medicare Advantage plans can appear hard to refute due to the criteria laid out by CMS and health plans. However, significant risk factors such as prior recent strokes and urinary tract infections, especially in older patients, are reason enough to attempt to reverse the initial denial. See one case in which an AppriseMD Payer Peer-to-Peer with UHC resulted in the reversal of one such denial.
CLINICAL SUMMARY: Elderly Patient with Significant Risk Factors
An 87-year-old patient was admitted to the hospital with stroke-like symptoms and evaluation of a cerebrovascular accident (CVA) with left arm sensory changes. The patient had a history of two recent strokes, coronary artery disease (CAD) and atrial fibrillation (AF). The initial NIHSS score was 1 and neurology was consulted but the patient was not a tissue plasminogen activator (tPA) candidate and was unable to tolerate an MRI. The CTA was negative for large vessel occlusion and an echo with bubble results were negative for shunt. The patient did, however, test positive for a urinary tract infection (UTI) and was placed on Rocephin.
Doctors admitted the patient in inpatient status based on the risk factors and the UTI, which required IV antibiotics. The patient remained hospitalized and continued IV ceftriaxone with neurology monitoring for hospital day two. The patient was not taking Plavix, so doctors started Plavix prior to discharge on hospital day three.
DENIED INPATIENT STAY
United Healthcare (UHC) Medicare Advantage denied the inpatient stay based on Medicare and health plan criteria that states a “member must show signs and/or symptoms severe enough to need services that can only be provided safely and effectively on an inpatient basis.” The denial stated that there was no available documentation of an insufficient response to treatment, nor a need for intervention or a condition not likely to improve at a lower level of care (LOC). Without significant clinical or lab findings, the carrier determined the LOC was not appropriate and denied the acute inpatient hospital admission.
THE APPRISEMD PROCESS
AppriseMD conducted a payer peer-to-peer with UHC’s medical director to discuss the case in detail. Reasoning that inpatient level of care was appropriate due to the risk factors of the elderly patient with recent stroke history as well as an active UTI needing IV antibiotics, AppriseMD walked through all the clinical care involved in the case, including the difficulties with MRI testing. As a result of the discussion, UHC reversed the inpatient denial and approved the claim based on the symptoms in the setting of significant risk factors and prior strokes.
OUTCOME: DENIAL OVERTURNED