CLINICAL SUMMARY:
A 22-year-old patient, four weeks postpartum, arrived in the emergency department suffering from abdominal pain and nausea. An ultrasound revealed the common bile duct was dilated to 8 mm, and a CT scan showed gallstones. In addition to steatosis, the patient also had a positive Murphy’s sign. Lab tests performed during the patient’s initial visit indicated a total bilirubin of 1.7, Alkaline phosphatase (ALP) level of 161, alanine transaminase (ALT) level of 101 and aspartate aminotransferase (AST) level of 113. The patient’s total bilirubin increased to 3.9, and the patient was admitted by the treating physician. The patient was then transferred to a second hospital for an endoscopic retrograde cholangiopancreatography (ERCP) to clear the bile duct. Tests at the second hospital confirmed the elevated bilirubin level of 3.1 and increased ALP of 276. Additional labs showed white blood cell (WBC) count of 7.26, hemoglobin (HGB) of 11.3, BUN 9, ALT 126 and AST 80. The patient remained in pain and required pain medication. In addition to the ERCP, doctors performed a sphincterotomy and stone removal. A general surgical consultation recommended a cholecystectomy, which was subsequently performed.
DENIED INPATIENT STAY
The insurance company denied this inpatient hospital stay, stating that it had reviewed medical records along with the patient’s health plan rules. The denial was based on the fact that “this high level of care was not medically necessary for the treatments.” It cited the lack of infection, a drop in blood pressure, confusion, or liver damage as examples. The denial letter stated, “You had surgery on your gall bladder through a tiny hole in your abdomen. The treatments and testing did not require the acute inpatient level of care.”
THE APPRISEMD METHOD
THE APPRISEMD METHODAn AppriseMD physician advisor spoke with the insurance provider’s medical director during a peer-to-peer review of the denied inpatient admission. The AppriseMD physician advisor reviewed the details of the case, discussing the suspected cholecystitis. This resulted in the patient being transferred to a higher level of care for additional treatment. While the patient underwent an ERCP and an uncomplicated laparoscopic cholecystectomy, a key point in getting the denial overturned was the physician advisor pointing out that there was evidence of biliary obstruction, as suggested by the patient’s bilirubin levels. The patient’s history, interventions, and bilirubin of 3.1 did support inpatient level of care. The persistence of the AppriseMD physician advisor resulted in the insurance company medical director overturning the denial.