Inpatient stays for procedures commonly done on an outpatient basis can lead to denials. But appealing the denials does have promise. A recent denial for a total knee replacement that was overturned due to the patient’s high risk factors and complex medical history.
CLINICAL SUMMARY: Total Knee Replacement
A 67-year-old patient underwent a left total knee replacement and was admitted to the orthopedic floor and monitored by the internal medicine team for a two-day hospital stay following the operation. The patient was placed on Lovenox and Eliquis for deep vein thrombosis (DVT) prophylaxis. Postoperative X-rays showed the prosthetic components fixed and in good position; activity began the night of the procedure. On postoperative day one, the patient continued to ambulate with PT and was able to bear weight on both legs. Pain was controlled using a multimodal approach of oral medications. PT remained unremarkable and the patient was cleared medically and orthopedically for discharge after two midnights.
DENIED INPATIENT STAY
The insurance company did not provide a reason for denying the level of care for the hospitalization for the TKA procedure.
PEER-TO-PEER DISCUSSION
An AppriseMD physician advisor spoke with the insurance company medical director regarding the denial. The patient’s medical history was discussed during the call, including the patient’s coronary artery bypass graft surgery in 2021, hypertension, Hodgkin’s lymphoma and obstructive sleep apnea. The patient did not have any significant postoperative complications and was discharged after two midnights. After a lengthy conversation, AppriseMD was able to overturn the denial due to the significant medical history which made this patient a higher risk for the procedure.
OUTCOME: DENIAL OVERTURNED