Case Study

Case Study: Hyperemesis gravidarum 4-day inpatient stay

After overturning a four-day inpatient denial for a 13-week pregnant patient with hyperemesis gravidarum and severe pain, the insurance company medical director commented that it is very difficult to overturn these cases. Just another example of the importance of detailed follow-up Peer-to-Peer discussions, even in denied cases that seem “hopeless” to be overturned. CLINICAL SUMMARY: …

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P2P Review for Denied Inpatient Stay

Case Study: Hospital stay due to injury and complex medical history

According to the CDC’s National Center for Health Statistics*, there are 130 million visits a year to Emergency Departments, 35 million of which are injury related. Many injury-related ER visits do not result in admission to the hospital, but for those that do, hospital utilization review managers need to provide insurance companies sufficient documentation showing …

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P2P Review for Denied Inpatient Stay

Case Study: Alcohol withdrawal and AMA departure can still qualify as inpatient stay

Does leaving the hospital against medical advice (AMA) equal an outpatient short stay? Not necessarily. AppriseMD reviewed one inpatient denial case involving a patient who left the hospital AMA after a two-day stay due to severe alcohol withdrawal and seizures. The AppriseMD physician reviewer was able to overturn the denial after a discussion with the …

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P2P Review for Denied Inpatient Stay

Case Study: Alcohol withdrawal inpatient stay denial overturned based on care required

Alcohol withdrawal and a positive COVID infection resulted in an inpatient hospital stay for one patient; however, the insurance company denied the short stay. A detailed peer-to-peer discussion of this case with the insurance company overturned the denial based on the acute symptoms and the medical and supportive care required. CLINICAL SUMMARY: Alcohol Withdrawal A …

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P2P Review for Multiple Sclerosis Case

Case Study: Multiple Sclerosis inpatient stay denial upheld

Determining level of care as a live case review can be difficult when doctors are still waiting on imaging and deciding upon treatment plans. One such live case review involved a patient with multiple sclerosis as detailed here, which AppriseMD recommended for inpatient level of care. The insurance company denied the inpatient stay. After completing …

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P2P Review for Angina Case

Case Study: Chest Pain, Unstable Angina P2P reveals intricate case

Patients admitted to the hospital with chest pain and other significant findings in the ER can still be denied for inpatient stay by insurance companies. One case involving a patient with severe stenosis of the right coronary artery and another critical lesion shows how an initial denial by the insurance company can be overturned after …

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Peer To Peer Review for Hospital Cases

Case Study: Acute diverticulitis stay denied

Healthcare insurance companies often deny inpatient hospital stays if the information provided does not show intensity of services significant enough to need inpatient care. If the patient’s care is more intense than the medical record implies a Peer-to-Peer discussion can provide more critical information to the insurance company. CLINICAL SUMMARY: Acute Diverticulitis A 69-year-old female …

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