CLINICAL SUMMARY:
An 88-year-old patient with a complex cardiac history of chronic congestive heart failure and dilated cardiomyopathy arrived at the emergency department (ED) with worsening shortness of breath and intermittent dizziness. The patient’s medical history included COPD, dilated cardiomyopathy, ventricular tachycardia with implantable cardioverter-defibrillator (ICD) shocks, atrial fibrillation (for which the patient uses Eliquis®), abdominal aortic aneurysm status post-surgical repair, hypertension and multiple myeloma. Upon arrival, the ED staff found the patient’s heart rate normal, with an accompanying regular heart rhythm and no murmur. The patient breathed normally with a few crackles on auscultation, but otherwise no wheezing, rales or rhonchi
Upon arrival, the patient’s chart indicated she was hemodynamically stable, and labs were normal except for elevated brain natriuretic peptide (BNP) levels of 531. Chest X-ray showed mild pulmonary edema and bibasilar atelectasis. The patient began receiving IV Lasix three times a day and IV magnesium sulfate. The patient continued telemetry, monitoring orthostatic vital signs, along with physical therapy (PT) and occupational therapy (OT) while the cardiac device interrogation was pending. A chest X-ray revealed bibasilar opacities, likely representing atelectasis with mild pulmonary edema. In the ED, the patient’s saturation dropped below 90% to a reported oxygen saturation in the 70s, requiring 1-2L of oxygen.
The following day, treating physicians noted that the patient was breathing comfortably on room air without wheezing, coughing, chest pain or pressure, nausea or diaphoresis, and discharged the patient after one midnight. The patient was discharged under strict guidelines after being transitioned to oral Lasix that would require daily doses, as well as daily weights and a repeat basic metabolic panel (BMP) in a week.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe Medicare Advantage (MA) payer denied this inpatient stay based on Medicare and health plan criteria. The payer used Traditional Medicare and MA coverage rules to review the clinical information and concluded it did not meet inpatient criteria because of a lack of complex medical factors to support an inpatient level of care (LOC). Furthermore, the denial indicated that symptoms did not persist after treatment and there was no documented diuresis.
THE APPRISEMD METHOD
THE APPRISEMD METHODThe hospital consulted AppriseMD for a secondary review on this case at the time of admission. The AppriseMD physician advisor reviewed the case in detail and recommended inpatient LOC due to the need for IV diuresis, continued monitoring and the likeliness that the patient would require more than two midnights of hospital-level care. When the payer denied the inpatient admission, AppriseMD was contacted again to facilitate a peer-to-peer review with the insurance company. During this call, the AppriseMD physician advisor reviewed the details with the payor medical director, including the fact that this patient had a complex cardiac history and was treated with IV Lasix and IV magnesium. Even though the patient had significant clinical improvement and was discharged on hospital day two, AppriseMD argued for inpatient LOC based on the severity of illness. The patient presented with a reported oxygen saturation in the 70s and required continuous supplemental oxygen with aggressive IV diuresis on hospital day 1 that included IV Lasix of 20 mg three times a day. The inpatient LOC recommendation was predicated on the likelihood of the patient requiring two midnights of active care. Using the Center for Medicare and Medicaid Services’ (CMS) Two-Midnight Rule, the denial was successfully overturned despite the one overnight stay.
AppriseMD physician advisors have at least five years of hospital-based clinical experience and three years of utilization management experience. This case study proudly demonstrates how AppriseMD utilization review physician advisors can get denials overturned so that hospital can be fairly reimbursed for services they provide.