CLINICAL SUMMARY:
A 70-year-old patient arrived in the Emergency Department (ED) from an assisted living facility (ALF) as his renal function deteriorated, and he slipped into a severely depressive state. The patient appeared pale and withdrawn, and the ALF staff reported that the patient did not eat or drink for approximately three weeks. Additionally, the patient communicated no bowel movement in the same time frame, in addition to a loss of 20 pounds in the last 90 days. The patient’s medical history included Crohn’s disease, paroxysmal atrial fibrillation, chronic anticoagulation, lower extremity deep vein thrombosis, chronic kidney disease, gastrointestinal (GI) bleed, ileus, nicotine dependency and chronic obstructive pulmonary disease (COPD). The patient had multiple ED visits, including a recent hospitalization greater than 30 days prior to this admission for ileus status post (s/p) colonoscopy with polypectomy due to lower GI bleed. The patient denied abdominal pain, nausea, vomiting, chest discomfort, shortness of breath, palpitations and paroxysmal nocturnal dyspnea, and told physicians there was nothing specific causing his symptoms.
Doctors spoke to the patient’s family who indicated the patient’s depression; he continued to take his medication but refused oral intake, was not answering his phone, withdrawing and refusing to engage in activities of daily living (ADLs). Vital signs upon admission were T 97.5, HR 57-58 (<60 x2), RR 18, BP 132/64-139/69, SpO2 >97% on RA. Labs upon admission were: WBC: 10.98, Hb: 14.5, PLT: 266, Na: 138, K: 3.4, BUN: 31, Cr: 2.47 (BL~2), Glu: 123. The patient was admitted for inpatient level of care (LOC) for failure to thrive and placed on IVF infusion 75 mL/h along with supportive care. Psychiatry and nephrology were consulted. AppriseMD conducted a secondary physician utilization review and due to ongoing medical care requiring close monitoring, AppriseMD’s physician advisor recommended inpatient LOC as they expected the patient would likely require at least two midnights of hospital care.
Three days later, the patient’s poor appetite and depression continued, though he did not exhibit suicidal ideation or exhibit signs of self harm. He remained hospitalized for failure to thrive, acute kidney injury as his creatinine improved but remained low, and major depressive disorder which contributed to his ongoing care needs; especially to decreased oral intake and dehydration. AppriseMD’s physician advisor concluded the patient was not yet medically optimized to transfer to an alternate location given ongoing care, kidney issues, and need for continued monitoring. For these reasons, they agreed that inpatient LOC was warranted and supported during a re-review of the continued stay.
INPATIENT STAY DENIAL
INPATIENT STAY DENIALThe patient’s Medicare Advantage (MA) plan determined that the inpatient admission status was “not reasonable and necessary” and did not meet criteria or policies adopted by Medicare, nor did it meet the Two-Midnight rule. The denial included a long list of conditions and symptoms which would have met criteria or demonstrated that observation LOC was not appropriate. It also stated that its supplemental policy was used to supplement and interpret Medicare requirements to determine medical necessity and clarify complex medical factors.
THE APPRISEMD PROCESS
THE APPRISEMD PROCESSAn AppriseMD physician advisor completed a peer-to-peer (P2P) discussion with the MA plan’s medical director in efforts to overturn the denial. They reviewed the 70-year-old patient’s admission for evaluation of failure to thrive, including that the patient was treated with 0.45 normal saline and then lactated Ringer’s at 100 mL/h. Following the discussion, the MA medical director concluded that inpatient LOC was met and approved. This included active care spanning multiple days, along with additional conversation around slow rising creatinine levels after IV fluids were stopped and oral Bumex was resumed.
Further deliberation covered the patient’s hospitalization the month prior, transpiring 31 days before the patient presented to the ED, not 30 days prior. While this admission occurred due to a readmission, AppriseMD was able to
get the two hospitalizations unlinked during the P2P review. Ultimately the MA medical director followed the Two-Midnight rule when inpatient LOC was supported, and the denial overturned.