Case Study

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Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial

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 […]

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Doctor visits patient post-surgery in the hospital.

Case Study: Post-Surgery Inpatient Admission Denial Overturned

CLINICAL SUMMARY: Post-Surgery Inpatient Admission Deemed Medically Unnecessary Overturned A 52-year-old patient underwent a planned ventral incisional hernia operation, performed laparoscopically using an intraperitoneal onlay mesh placement. The patient was classified as ASA Class III, defined by the American Society for Anesthesiologists (ASA) for patients with “severe systemic disease that is not incapacitating” with a

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Physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.

Case Study: Medical Necessity Behind Short Stay is Key

CLINICAL SUMMARY: Medical Necessity Behind Short Stay is Key This case involves a one-day inpatient denial for a 30-year-old patient treated for acute pancreatitis. With abdominal pain and nausea, the patient went to the Emergency Department where he was found to have upper abdominal pain and tenderness, a lipase of 1,447 U/L (reference range 16-77

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Physicians in operating room

Case Study: TKA Inpatient Status Denied Despite Being on CMS Inpatient Only List

Insurance companies are more likely to approve inpatient status for surgeries included on the CMS Inpatient Only List (IPO). Total knee replacements and total hip replacements are two common procedures on the IPO list. A Peer-to-Peer review can help reverse a denial for a inpatient stay for these types of cases. CLINICAL SUMMARY: TKA Inpatient

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patient in wheelchair

Case Study: Inpatient Denial Overturned for Elderly Patient with Significant Risk Factors

Inpatient denials for elderly patients on Medicare Advantage plans can appear hard to refute due to the criteria laid out by CMS and health plans. However, significant risk factors such as prior recent strokes and urinary tract infections, especially in older patients, are reason enough to attempt to reverse the initial denial. See one case

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Hospital hallway with wheelchairs for discharge

Case Study: Awaiting Discharge to Skilled Nursing Facility

Extended hospital stays where a patient is medically ready to discharge but awaiting admission into a Skilled Nursing Facility or Acute Inpatient Rehabilitation continues to be an issue and can lead to revenue loss. AppriseMD recently overturned an inpatient denial for an 11-day hospital stay that was extended awaiting discharge. CLINICAL SUMMARY: Awaiting discharge to

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Diabetic patient testing blood

Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned

Hospital utilization management requires constant communication between the utilization management team and physician advisors as well as continuously reassessing observation cases for possible conversion to inpatient status. Missing these opportunities leads to increased observation rates, reduced revenue, and potential Patients requiring ongoing medical care beyond the observation period should be constantly reassessed for inpatient status

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Patient with total knee replacement

Case Study: Total Knee Replacement Inpatient Denial Overturned

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

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patient sitting alone in hospital room

Case Study: Type 2 Diabetes and Chronic Kidney Disease

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

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