CLINICAL SUMMARY:
A 50-year-old patient was hospitalized overnight after arriving in the emergency room with constant left flank pain. The patient was seen in the emergency room (ER) the previous week with similar symptoms, which doctors diagnosed as a 5 mm, left proximal ureteral stone with mild hydroureteronephrosis. The patient was treated and sent home with plans to follow up with urology in an outpatient setting. The patient returned to the hospital six days later unable to move due to pain, intractable to the prescribed Toradol and Flomax. The patient also experienced nausea and vomiting, therefore unable to take the prescribed oral medication. The primary care physician sent the patient to the ER due to worsening and uncontrolled pain. The patient had a past medical history of diverticulitis, sleep apnea, high body mass index (BMI) and nephrolithiasis. Labs taken during the second hospital visit showed normal white blood cell count, stable vital signs and slightly elevated blood pressure of 107-159 systolic, 70-102 diastolic.
Due to the ongoing nausea and vomiting, the patient required IV Dilaudid for pain control. Doctors performed a computed tomography (CT) scan which revealed a 5 mm proximal left ureteral stone in the distal left ureter causing mild hydronephrosis with no infection. Doctors performed an urgent cystoscopy, placing a left ureteral stent, which was followed by a left ureteroscopy due to refractory pain with no complications. The patient remained stable overnight — pain improved drastically. The patient’s blood pressure remained elevated at 138/83-164/97, and doctors advised the patient’s primary care physician about future blood pressure lowering medications. The patient was discharged after the one-night stay.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe insurance company denied the overnight hospital stay due to lack of medical necessity. The denial stated that the care could have been provided in an observation setting and that an inpatient stay was not required due to lack of unstable blood pressure or trouble breathing. This decision was based on MCG guidelines for renal colic and kidney stone treatment.
THE APPRISEMD METHOD
THE APPRISEMD METHODAn AppriseMD physician advisor conducted a peer-to-peer discussion with the insurance company medical director, highlighting that the patient’s condition was unable to be managed in the outpatient setting. The AppriseMD physician advisor explained that the patient first presented in the ER with renal colic six days prior to the overnight hospital stay. The patient was treated during the first ER visit, and then discharged with follow up in the outpatient setting. However, the patient returned to the hospital six days later in severe pain that was accompanied by nausea and vomiting. Doctors treated the patient with IV Dilaudid, intramuscular Toradol, IV Zofran twice and IV fluids. The AppriseMD physician advisor also reminded the payer medical director that the patient underwent a cystoscopy and stent placement. After a lengthy discussion, the inpatient level of care short stay was approved due to the failure of outpatient management, re-presentation to the emergency department and the additional factor of a 46.6 BMI, which complicates overall care.
This case exemplifies the value of using physician advisors with experience on both the payer and clinical side who advocate for the providers and their patients. Even notoriously difficult cases like this one-night, short hospital stay can be approved when you have the right team campaigning on your behalf.