CLINICAL SUMMARY:
Doctors performed a scheduled hysteroscopy with dilation and curettage (D&C), endocervical myomectomy and MyoSure polypectomy on a 55-year-old patient who had been experiencing abnormal uterine bleeding with cervical fibroids and an endometrial polyp. The patient had a medical history which included pancreatitis due to alcoholism with a pseudocyst, deep venous thrombosis, hypertension, pleural effusion, postoperative nausea/vomiting, pulmonary embolism and transient ischemic attacks. This patient’s history also included multiple surgeries consisting of a hernia repair with mesh placement and an exploratory laparotomy with removal of the pancreas, gallbladder and spleen, during which her bowels were injured. She required an ostomy for a period, but it has since been reversed.
The procedure in question was needed to remove a fibroid that was distorting the patient’s anatomy, making it impossible to adequately evaluate her endometrium. Prior to the procedure, doctors completed a complete blood count, basic metabolic panel, electrocardiogram and trans vaginal ultrasound. The procedure was completed without complications, and the patient was discharged home for self-care post-surgery.
INPATIENT STAY DENIAL
The insurance company denied the inpatient level of care (LOC) for the services, which it called “female surgery,” noting the fact that the patient was in the hospital for less than 24 hours. The denial noted that the inpatient status did not meet medical necessity because the patient’s vitals were normal, with no uncontrolled bleeding and no surgical complications. Even though the documentation supported the IPO list, a guideline of services that support inpatient LOC by Medicare, the insurance company stated that “observation level of care is an option” based on the patient’s health plan rules.
THE APPRISEMD METHOD
An AppriseMD physician advisor conducted a peer-to-peer discussion with the insurance company’s medical director regarding the denied admission. The physician advisor highlighted the fact that the patient was directly admitted for a scheduled hysteroscopy D&C with a MyoSure myomectomy, a procedure which is on the inpatient-only list. Based on the documentation of the IPO list, combined with the discussion facilitated by the AppriseMD physician advisor, the denial was overturned. This resulted in inpatient LOC being approved for this high risk and complex surgery even though this patient was discharged on the day of surgery. While Medicare and Medicare Advantage plans follow the IPO list, commercial and managed Medicaid plans do not always need to follow the IPO list, making this case a good example that highlights why hospitals trust AppriseMD to handle their denials. Experience counts, and that is why AppriseMD physician advisors have at least five years of clinical experience combined with three years of utilization management experience.