Insurance companies are more likely to approve inpatient status for surgeries included on the CMS Inpatient Only List (IPO). Total knee replacements and total hip replacements are two common procedures on the IPO list. A Peer-to-Peer review can help reverse a denial for a inpatient stay for these types of cases.
CLINICAL SUMMARY: TKA Inpatient Status Denied Despite Being on CMS IPO List
A 67-year-old patient’s total knee revision as a second stage surgery was denied as an inpatient stay. The patient had a prior history of an infected total knee replacement with a spacer implant along with a standing medical history which included hypertension, emphysema, gastroesophageal reflux disease and depression. The patient was admitted as an inpatient for the removal of the implant and placement of a TKA.
DENIED INPATIENT STAY
The denial was based on information the insurance company received regarding the patient’s condition as well as MCG General Recovery Guidelines for Ambulatory Surgery or Procedures. According to the denial, inpatient level of care was not medically necessary under the member’s plan. The statement listed a series of pre-operative diseases that could not be managed in an outpatient setting which it said that patient did not meet.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor completed a peer-to-peer discussion with the insurance company medical director which involved a lengthy discussion of the case and its intricacies, including the history of infection with the total knee replacement. The initial denial was upheld based on the prior authorization of outpatient care. However, AppriseMD’s physician advisor argued that inpatient was appropriate because the total knee revision is an inpatient only surgery according to the CMS’s Inpatient Only List (IPO). AppriseMD’s physician advisor asked the insurance company to look up the correct CPT code for a knee revision and, based on the IPO, the inpatient status was approved, and the denial was overturned.