Even with concerns about days spent waiting on a transfer to a higher level of care, an insurance company medical director reversed an inpatient stay denial after a Peer-to-Peer discussion of the case.
CLINICAL SUMMARY: Type 2 Diabetes and Chronic Kidney Disease
A 40-year-old patient arrived in the Emergency Department complaining of worsening right upper quadrant abdominal pain with a hard lump in the epigastric area. The patient – who has a history of Type 2 diabetes, hypertension, necrotizing, pancreatitis, and chronic kidney disease – suffered symptoms for approximately one week. The patient was on insulin and visits a pain clinic for chronic pancreatitis.
Doctors performed a CT scan which showed a new peripherally enhancing fluid collection in the right upper quadrant of the abdomen adjacent to a pancreatic pseudocyst possibly suggestive of an abscess formation as well as an increase in the size of the pancreatic pseudocyst. General surgery was consulted for assistance and treating physicians contacted the University of Iowa, which agreed to accept the patient for transfer but did not have a bed available. The patient was admitted as an inpatient and given Dilaudid for pain, awaiting a call back when a bed was available at the University of Iowa.
The admitting hospital continued to communicate with University of Iowa about a transfer as it cared for the patient. The patient began long-acting oxycodone 10 mg every 12 hours with Norco as needed. That dosage was increased to 20 mg twice a day and Norco upped to 10-20 every four hours on the third day of hospitalization. The patient was also given 20 of IV Lasix. Doctors began discontinuing Dilaudid as pain control improved the following day. The patient was discharged after six days in the hospital once there was no longer a need for IV pain medications. Doctors ensured follow-up care with a primary care provider and sent the patient home with prescriptions for insulin.
DENIED INPATIENT STAY
The insurance company medical director denied the acute care level noting the pseudocyst and a review of the patient’s records which showed a history of pancreatic problems and type 2 diabetes. The denial letter stated the patient had been treated in the past for pancreatic problems and made note of the fact that the patient was on pancreatic enzyme replacements due to inadequate release of pancreatic enzymes into the intestines. A lower level of care was approved for the hospital stay, reasoning that the patient was waiting for a transfer to a tertiary for definitive care.
PEER-TO-PEER DISCUSSION
PEER-TO-PEER DISCUSSIONAppriseMD’s physician advisor spoke to the insurance company medical director regarding the case. He pointed out the fact that the patient was admitted for recurrent pancreatitis and multiple pseudocysts with possible abscess formation. Also discussed was the fact that the patient was treated with multiple doses of IV pain medications and had a surgery evaluation. Even on the third day in the hospital, the patient continued to need seven doses of Dilaudid via an IV. AppriseMD maintained that given the need for IV pain medication and IV Zosyn, care moved beyond observation care.
The Peer-to-Peer discussion resulted in the approval of an inpatient level of care, overturning the denial. However, the insurance company did raise quality concerns with this case. The patient required a higher level of care and multiple days were spent waiting on transfer to a higher level of care at the University of Iowa. The insurance company medical director felt it was important to seek alternate centers if no beds were available initially and saw the need for a quality review.
OUTCOME: DENIAL OVERTURNED