AppriseMD’s latest case study centers on a patient that was hospitalized for chest pain, and the claim was denied based on unproven medical necessity and a lack of reasonable expectation of hospitalization that crossed two midnights.

Case Study: Medical Necessity and Reasonable Expectations

/ Case Study, Denial Management, Medical Necessity, Peer-to-Peer, Two-Midnight Rule / By

CLINICAL SUMMARY:

A 73-year-old patient’s primary care doctor sent her to the Emergency Department (ED) after multiple labs taken for continuing chest pains showed abnormal results. The patient, who had been suffering chest pain for more than a week and who was taking nitroglycerin, had a stent placed in April. The patient had an extensive medical history that included hypertension, diabetes, dyslipidemia, chronic kidney disease (CKD) stage IV, coronary artery disease, and right heel osteomyelitis. In the ED, the patient was not tachycardic nor hemodynamically unstable. The patient’s initial troponins were mildly elevated with no acute coronary syndrome trend and an EKG showed no acute ischemic changes. The patient showed elevated levels of B-type natriuretic peptide (BNP) and mildly elevated D-dimer but was not hypoxemic. Doctors started the patient on a heparin drip and admitted her for inpatient hospital care.

Doctors monitored the patient with telemetry and consulted both nephrology and cardiology. Admission labs showed the following results:

  • WBC 12.46
  • Hgb 9.1
  • Na 140
  • K 5.1
  • BUN 41
  • Cr 2.87 (baseline 2.91)
  • APTT 40.3
  • NT-pro BNP 2184
  • CKMD 2.4
  • Trop T 5th Gen (range <11ng/dL) 52, 50
  • D-dimer 1579
  • EKG = normal axis, normal intervals, no acute ischemia
  • Chest X-rays showed increased interstitial prominence

Doctors noted that the patient’s symptoms were most likely due to acute chronic diastolic heart failure. The attending staff administered intravenous (IV) Lasix in the ED followed by one dose of IV Bumex. Nephrology concluded the patient was depleted. An echocardiogram showed normal left ventricular size and systolic function. Visually, doctors estimated ejection fraction at 60-65% with moderate aortic valve stenosis and no aortic valve regurgitation. The mean gradient was noted at 26 mmHg.

Cardiologists performed a coronary angiogram which showed no blockages. The patient’s hemoglobin A1c ranked at 6.1% and dual antiplatelet therapy continued. Doctors also noted anemia of chronic disease and continued metoprolol, isosorbide, and fenofibrate for the coronary artery disease.

Doctors treated the patient with heparin and pulmonary ventilation, and they performed a perfusion scan to evaluate for pulmonary embolism (PE). The patient exhibited no clinical signs of PE or deep vein thrombosis, nor did the patient have risk factors or a prior history of either. Finally, the wound team dressed the patient’s heel to address the chronic osteomyelitis. The patient was discharged on day three.

Patient chart iconINPATIENT STAY DENIAL

The patient’s insurance provider denied the inpatient level of care for this three-day hospital admission because it did not meet the requirements under its policy, which considers inpatient admission criteria outlined by the Centers for Medicare and Medicaid (CMS). The denial stated that “in order for the inpatient hospital admission to be appropriate for coverage under Medicare Part A, CMS requires that the admitting physician have a reasonable expectation that the patient requires medically necessary hospital care that crosses two midnights, based on complex medical factors supported by the medical record documentation.” However, the patient’s medical record documentation did not support such medical necessity. The insurance company specifically noted that the patient was not hemodynamically unstable nor were the patient’s chest pains caused by a heart attack or another “dangerous” condition such as an aortic dissection. The denial further stated that the patient’s chest pain did not require IV medication for an extended period. Based on those factors, the insurance provider concluded that the patient did not have the “complex medical factors that would require prolonged workup and treatment in the hospital to support a reasonable expectation” for a length of stay that crossed two midnights.

Patient chart review iconTHE APPRISEMD METHOD

The hospital asked AppriseMD to complete a peer-to-peer discussion with the insurance provider regarding the denied reimbursement on a case that included an extensive evaluation and a two-part test to check for a blood clot in the lungs. The AppriseMD physician advisor reviewed the case with the payer and discussed how doctors
completed a Doppler ultrasound and placed the patient on a Heparin infusion as well as IV diuresis. The physician advisor also communicated that the patient required a nephrology consultation due to intravascular depletion, as well as a cardiology consultation that resulted in a cardiac catheterization. The patient required cardiac catheterization in the setting of severe renal insufficiency, increasing the risk of further renal dysfunction. Therefore, the cardiac catheterization was high risk, requiring inpatient status. While the catheterization was negative, the physician advisor reminded the payer that it was ordered based on the elevated risk features that cardiology felt warranted angiography despite CKD.

The insurance company ultimately approved the inpatient level of care since the cardiologist was worried enough to perform a catheterization in the setting of CKD, thus showing a high pretest probability. The patient requiring IV diuresis in the setting of renal insufficiency also required inpatient status, which was another factor in the insurance company’s rescission of the denial. This resulted in a higher level of reimbursement for the hospital.

OUTCOME: DENIAL RESCINDED AFTER PEER-TO-PEER, REIMBURSEMENT INCREASE

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