Case Study

AppriseMD Case Study Challenging MA denial overturned despite one-midnight stay

Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay

Case Study, Two-Midnight Rule / By

CLINICAL SUMMARY: A 76-year-old female arrived at the emergency department critically ill, experiencing palpitations and shortness of breath. The patient had a complex medical history including ovarian and thyroid cancers, chronic heart failure (CHF) with reduced ejection fraction (EF 20%), stage 3b chronic kidney disease, gastroesophageal reflux disease, paroxysmal atrial fibrillation (A-fib) on anticoagulation, type 2 […]

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Nurse checks on infant in hospital

Case Study: Infant Failure to Thrive Inpatient Denial Overturned

Case Study, Medicaid, Peer-to-Peer / By

CLINICAL SUMMARY: A newborn infant, just over one-month-old, arrived at the Emergency Department (ED) under the direction of a pediatrician, who was concerned about lack of weight gain since birth. The infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. The patient’s weight

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Case Study Readmission Unlinked after P2P

Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review

Case Study, Peer-to-Peer, Readmission / By

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 The patient appeared pale and withdrawn, and the ALF staff reported that the patient did not eat or drink for approximately three weeks.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

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Patient in ER for cellulitis

Case Study: Secondary Review Recommendation Holds in Cellulitis Hospitalization

Case Study, Denial Management, Second-Level Review / By

CLINICAL SUMMARY: A 35-year-old patient arrived in the Emergency Department suffering from a painful abscess and swelling on the left buttock. The patient, whose medical history includes hidradenitis suppurativa, bipolar 1 disorder and asthma, described the pain as an excruciating stabbing sensation rated at a level 10. Furthermore, the patient reported shortness out of breath

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Doctors work on a patient in the Emergency Department

Case Study: New DRG Key to Overturning MCO Denial

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 34-year-old patient arrived in the emergency department (ED) experiencing complications from alcohol withdrawal, which began while staying at a sober living home. He began experiencing lightheadedness, nausea, vomiting and epigastric pain in addition to developing a bilateral rash to his upper extremities and was transported to the ED. The patient reported drinking

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Doctor performs labs in emergency department.

Case Study: Readmission Linking Denial Overturned After P2P

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 79-year-old male patient arrived in the emergency department (ED) complaining of weakness, extreme lethargy and the inability to eat for the past three days. The patient’s past medical history included prostate cancer s/p resection with metastases to the bladder and lumbar spine on antiandrogen, hypothyroidism, hypertension, hyperlipidemia, CAD s/p stent placement x2,

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emergency-hospital-sign

Case Study: Profound Obesity Risk Factor Overturns Denied Inpatient Stay

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A 29-year-old male patient with no significant past medical history arrived at the Emergency Department with ongoing abdominal pain, cramping and tenderness in the left upper quadrant and epigastric region. This patient presented with a weight of 523 pounds, a BMI of 87 and labs as follows: WBC 12.07, ANC 9.34, Hgb 13.4,

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patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy

Case Study: Short Stay Involving a Patient with Lennox-Gastaut Syndrome Highlights the Need for P2P

Case Study, Denial Management, Peer-to-Peer / By

CLINICAL SUMMARY: A six-year-old male patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy, arrived in the emergency department (ED) after experiencing breakthrough cluster seizures at home and en route to the hospital after starting a new treatment medication the day prior. Once in the ED, the patient experienced three more seizures, one

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MA patient in hospital

Case Study: MA Denial Overturned

Case Study, Medicare Advantage, Peer-to-Peer, Two-Midnight Rule / By

AppriseMD recently argued that the presence of a rise in creatinine constituted hypertensive end-organ damage, which was the key factor for a Medicare Advantage denial being overturned. CLINICAL SUMMARY: An elderly patient with a history of hypertension and thyroid disease sought treatment in the emergency department after a fall. The patient suffered a closed head

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AppriseMD Case Study: Complex Medical History, ICD & Transfer Impact Inpatient Denial Reversal

Case Study: Complex Medical History, ICD & Transfer Impacts Inpatient Denial

Case Study, Denial Management, Peer-to-Peer / By

An inpatient level of care (LOC), initially denied by a Medicare Advantage payer, was approved after a peer-to-peer discussion involving a stable patient with a complex medical history and condition that required a transfer to a higher LOC. The short stay exemplifies the importance of having physicians with both payer and clinical experience facilitate the

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