Peer-to-peer for Inpatient Denial

Case Study: Sepsis Presents Challenging Denial


This case involved a 74-year-old patient who presented with chills and a temperature of 103°F. The patient had a past history of hypertension, arthritis, and right total shoulder replacement in January 2021. Chest x-ray showed coarse perihilar and interstitial markings, likely viral or reactive. A CTA chest was negative for pulmonary embolism or acute pulmonary disease. A urine test was nitrate positive with trace leukocyte esterase. Blood cultures were drawn, and urine was sent for culture.


The patient began a course of ceftriaxone and fluid resuscitated and was admitted for further management. During the three-day hospitalization, the urine culture came back growing gram-negative rods but the patient’s heart rate, temperature, and BP normalized. The patient worked with physical therapy and was transitioned to oral antibiotics and was stable for discharge after the third day. The insurance provider stated in a denial letter that coverage for an “acute admission” was denied because “medical necessity criteria were not met based upon MCG.” It stated the rationale for the decision was no IV vasopressors required, improved BP on day two as well as no repeated IV fluid, no AMS, no AKI and no urinary system finding required invasive procedures.


The patient was admitted for sepsis from a UTI and a P2P discussion between AppriseMD and the insurance company followed the initial denial. The denial was challenging to overturn, but after a lengthy discussion on the patient’s high BMI (>50), recent shoulder surgery, and three-day length of stay, the case was approved for an inpatient stay. The denial was overturned.



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