CLINICAL SUMMARY: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial
A 68-year-old patient with an extensive medical history arrived at the emergency room after three days of acute gastrointestinal (GI) bleeding. The patient experienced nausea and observed bright red stool blood that persisted. The patient’s medical history included atrial fibrillation treated with an ablation and maintained with Xarelto, abdominal aortic aneurysm, chronic kidney disease, coronary artery disease treated twice with stenting and maintained with Plavix. He also had a history of hypertension, depression, large ventral hernia repair in conjunction with recurrent hernia, kidney stones and joint replacement. The patient reported a feeling of constipation and mild, lower abdominal pain, in conjunction with passing hard stool prior to admission. In the emergency room, the patient’s blood pressure dropped to 70/45. Doctors administered IV fluids, which resulted in blood pressure improvement. Other notable lab results included: hemoglobin down to 11.7, repeated hemoglobin was 10.7 and lactic acid of 2.3. Additional lab results reported: WBC 10.16, Hgb 9.4>10.7>11.7, PLTS 217, Na 140, K 3.9, BUN 16, Cr 0.65, GLUC 109. A CT scan of the abdomen showed no acute abnormality. Doctors found diverticulosis without evidence of diverticulitis and a 4.5 cm infrarenal abdominal aortic aneurysm unchanged.
SECONDARY REVIEW
The treating physician admitted the patient as inpatient for further evaluation and management, and the hospital utilization review team sent this case to AppriseMD for additional insight. The AppriseMD physician advisor agreed with the inpatient level of care during a secondary review, noting the need for a pending GI consult, ongoing clinical monitoring, and medical management.
DENIED INPATIENT STAY
DENIED INPATIENT STAYThe payer denied the inpatient level of care based on the Centers for Medicare & Medicaid Services (CMS) policy and plan guidelines. In the denial, the payer noted that the Medicare Benefit Policy Manual requires an inpatient admission under Medicare Part A when the treating physician “reasonably expects the patient to require hospital care that crosses two midnights” and the patient is not admitted for a “surgical procedure specified on the inpatient-only list.” This expectation by doctors should be based on “patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event” as stated in the denial letter. The denial also stated that the payer reviewed the patient’s case, and based on the information provided, a denial was issued due to “factors for coverage,” which the patient did not meet.
THE APPRISEMD METHOD
THE APPRISEMD METHODAn AppriseMD physician advisor completed a peer-to-peer discussion with the insurance company medical director regarding the denied inpatient stay for this Medicare Advantage patient with an extensive medical history and significant symptoms. During the call, the physicians discussed the fact that the patient was initially hypotensive and tachycardic but stabilized after starting proton-pump inhibitors (PPI) which were given intravenously for two days to address the GI bleed. The AppriseMD physician advisor also pointed out that the patient was on Xarelto, had lactic acidosis and a down trending hemoglobin while awaiting consultation. The payer medical director eventually reversed the initial denial determination based on discussion facilitated by the AppriseMD physician advisor, who addressed the high severity of illness, the Two-Midnight rule and the likelihood of a two-midnight hospitalization upon admission.