Peer To Peer Reviews for Hospital Cases

Case Study: Post C-section wound infection and asthma exacerbation denial overturned

A recently denied inpatient hospital admission for asthma exacerbation and wound infection was overturned when the insurance company was made aware of additional symptoms that doctors deemed high risk and worthy of a higher level of care. Clinical information sent by the hospital to the insurance company did not show the need for the extra level of care, but a Peer-to-Peer discussion resulted in the denial being overturned.

CLINICAL SUMMARY: Post C-section

A 36-year-old new mother with a recent C-section was admitted after an ER visit due to shortness of breath occurring since the delivery of her child and drainage from her surgical incision. The patient had a significant past medical history of morbid obesity, asthma, and sleep apnea. The physician summary showed the patient had acute toxic respiratory failure due to asthma exacerbation.


DENIED INPATIENT STAY

Aetna denied the hospital stay citing the information sent by the hospital did not show the need for extra oxygen or breathing treatments for more than 24 hours nor did it show problems with blood pressure or heartbeat.


PEER-TO-PEER DISCUSSION

A Peer-to-Peer was completed between an AppriseMD physician on behalf of the hospital and Aetna. The case was reviewed in detail. The AppriseMD physician communicated that the patient needed IV steroids and IV antibiotics. The case was overturned based on the patient’s high BMI (74) and active steroids which was a setup for antibiotic failure and a poor clinical outcome.

OUTCOME: DENIAL OVERTURNED

 

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