CLINICAL SUMMARY:
A 79-year-old male patient arrived in the emergency department (ED) complaining of weakness, extreme lethargy and the inability to eat for the past three days. The patient’s past medical history included prostate cancer s/p resection with metastases to the bladder and lumbar spine on antiandrogen, hypothyroidism, hypertension, hyperlipidemia, CAD s/p stent placement x2, COPD and nicotine dependence. Twenty-seven days prior to this presentation in the ED, the patient was discharged from the hospital after being treated for physical deconditioning and found to have metastatic lesions on imaging. Upon return to the ED, doctors discovered an RSV infection, asymptomatic UTI, as well as physical deconditioning.
Vital signs were as follows: T 97-99.3 F, HR 92-109 (>100 x8), RR 19-35 (>20 x12), BP 93/78-141/76, SpO2 95% RA. The physical exam showed the patient was alert and oriented to person, place and time; lungs were clear to auscultation, no wheezing or rhonchi, no respiratory distress, heart exhibited regular rate and rhythm, and the abdomen was without tenderness or distention. Labs included: WBC 5.94, Hgb 9.2, HCT 28.5, PLT 83 (12/11/24 181), Na 133, K 4.4, GLU 131, BUN 24, Cr 1.11, Albumin 3.3, TBili 1.1, ALP 991, AST 213, ALT 12, RSV was detected, CK 484, Protime 15.2, INR 1.2, NT-proBNP 995, UA: orange, turbid, ketones trace, protein 50, Urobil 4.0, Nitrite positive, LE large, RBC 7, WBC >50, bacteria few, squamous epithelial moderate, calcium phosphate crystals present. Chest x-ray showed mild bilateral interstitial opacities concerning for edema versus infection and a small left-sided pleural effusion.
Doctors admitted this high-risk patient with multiple comorbidities including metastatic prostate cancer as inpatient (IP) level of care (LOC) and this case was referred to AppriseMD for a second-level physician review. Our physician advisors agreed with the LOC based on the available medical documentation which included the presence of an RSV infection and progressive physical weakness. The patient received active medical management, including 40 mg IV Solu-Medrol and started on IV ceftriaxone, oral azithromycin and Duoneb inhaler along with supportive care indicating a need for hospital-based care beyond two midnights. Physical and occupational therapy were consulted for evaluation and possible need for placement.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe Medicare Advantage (MA) plan review concluded that the inpatient LOC services provided were not reasonable, necessary or covered in accordance with the policies adopted by Medicare, the CMS Program Integrity Manual, the payer or the patient’s plan. Subsequently, the claim was denied.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSPrior to the denial, the hospital referred this case to AppriseMD for a secondary review by a physician, and the AppriseMD physician advisor agreed with the hospital’s determination that the patient required IP LOC services. The payer, however, denied the claim, resulting in the hospital referring this case back to AppriseMD for a peer-to-peer (P2P) discussion with the payer.
AppriseMD scheduled the P2P, and the physician advisor uncovered that this was a 30-day readmission/DRG linking denial. The AppriseMD physician advisor explained how the patient’s prior admission was related to a fall and rhabdomyolysis. The physician advisor further clarified that the patient readmitted several weeks later due to shortness of breath secondary to an RSV infection and possible pneumonia; the admission under review. The physician advisor explained that the patient received IV antibiotics and supportive care, and that the patient’s respiratory status continued to worsen, requiring active medical management and further imaging as the patient remained in-house at the time of the peer-to-peer. Given the metastasis to the CNS with ongoing weakness and lethargy, as well as the need for IV steroids and IV antibiotics, inpatient admission was supported due to the high severity of illness and intensity of services.