P2P Review for Multiple Sclerosis Case

Case Study: Multiple Sclerosis inpatient stay denial upheld

Determining level of care as a live case review can be difficult when doctors are still waiting on imaging and deciding upon treatment plans. One such live case review involved a patient with multiple sclerosis as detailed here, which AppriseMD recommended for inpatient level of care. The insurance company denied the inpatient stay. After completing a Peer-to-Peer with the insurance company regarding the denial, AppriseMD agreed with the insurance company decision because a lower level of care was appropriate.

CLINICAL SUMMARY: Multiple Sclerosis

A 79-year-old female with a history of multiple sclerosis, hypertension, motion sickness, neuropathy, osteoporosis, renal insufficiency, UTIs arrived at the hospital feeling weakness in her lower extremities after a fall at home. She notably had received a COVID booster shot on the same day that she developed weakness and was unable to walk on her own. The patient was admitted and received a neurology consult for evaluation of what treating physicians thought could be a possible MS flare up. An MRI of the brain, cervical, and thoracic spine showed no active lesions except for a questionable enhancing small lesion posterior to the C7 vertebral body. All labs were normal, and the patient resumed her home medication regimen.

On the following day, the patient’s lower extremity weakness improved. Neurology obtained a carotid ultrasound to rule out all possible causes and found no significant carotid artery stenosis that may have contributed to her acute presentation. The patient received physical therapy and was able to ambulate around the room with no weakness in the extremities. Patient was discharged on the second hospital day to continue with her routine medications.


DENIED INPATIENT STAY

The insurance company denied the inpatient stay based on the fact that criteria was not met for an inpatient admission. The reason given was “no documentation of an insufficient response to treatment, need for intervention, or presence of a condition not likely to improve in a lower level of care.” The patient’s lab results did not show any abnormal or diagnostic finding and there were no specialized services received that could not have been provided in a lower level of care. Finally, there was no persistent hemodynamic instability, severe altered mental status, or neurological deficit found.

For those reasons, the inpatient hospital admission was denied.


PEER-TO-PEER DISCUSSION

AppriseMD reviewed this case on hospital day one as a live case review. With imaging pending and potential plans for further pharmacologic interventions, the AppriseMD physician recommended inpatient level of care at the time.

At AppriseMD we hold ourselves accountable when denied inpatient stays are upheld and we agree with the decision. AppriseMD will let the hospital know our further recommendation of whether or not it is worth the hospital’s effort to attempt an appeal. In this case, because the AppriseMD physician agreed with the upheld decision of the insurance company, we would advise against an attempt at an appeal.

Reviewing this case in retrospect, the AppriseMD physician agreed that the care provided could have been at a lower level of care.

OUTCOME: DENIAL UPHELD

Read more about MS

Read more AppriseMD Case Studies

Scroll to Top