CLINICAL SUMMARY: A 75-year-old male arrived at the Emergency Department with fevers, body aches, shortness of breath and chills. The patient had a medical history of Type 2 diabetes, hypertension and chronic urinary retention for which he self-catheterized. Additionally, the patient had diabetic peripheral neuropathy being treated with gabapentin, and he presented with elevated creatinine, […]
CLINICAL SUMMARY: A 73-year-old patient’s primary care doctor sent her to the Emergency Department (ED) after multiple labs taken for continuing chest pains showed abnormal results. The patient, who had been suffering chest pain for more than a week and who was taking nitroglycerin, had a stent placed in April. The patient had an extensive
Case Study: Medical Necessity and Reasonable Expectations Read More »
CLINICAL SUMMARY: An 88-year-old patient with a complex cardiac history of chronic congestive heart failure and dilated cardiomyopathy arrived at the emergency department (ED) with worsening shortness of breath and intermittent dizziness. The patient’s medical history included COPD, dilated cardiomyopathy, ventricular tachycardia with implantable cardioverter-defibrillator (ICD) shocks, atrial fibrillation (for which the patient uses Eliquis®),
Case Study: Physician Advisor Secondary Review Insight on MA Case Read More »
CLINICAL SUMMARY: Doctors performed a scheduled hysteroscopy with dilation and curettage (D&C), endocervical myomectomy and MyoSure polypectomy on a 55-year-old patient who had been experiencing abnormal uterine bleeding with cervical fibroids and an endometrial polyp. The patient had a medical history which included pancreatitis due to alcoholism with a pseudocyst, deep venous thrombosis, hypertension, pleural
Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay Read More »
CLINICAL SUMMARY: A 30-year-old patient arrived at the emergency room suffering from abdominal pain, nausea and vomiting. The patient’s symptoms had been occurring for the past six weeks and progressively worsened. The patient complained of pain in the upper abdomen that radiated to the back. The patient had a medical history of anxiety, asthma, depression,
Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission Read More »
CLINICAL SUMMARY: A 50-year-old patient was hospitalized overnight after arriving in the emergency room with constant left flank pain. The patient was seen in the emergency room (ER) the previous week with similar symptoms, which doctors diagnosed as a 5 mm, left proximal ureteral stone with mild hydroureteronephrosis. The patient was treated and sent home
Case Study: Overnight Short-Stay Denial Reversed Read More »
CLINICAL SUMMARY: Recently, physicians admitted a 73-year-old patient with an extensive medical history twice within an 8-day period. The patient required inpatient level of care (LOC) for both hospitalizations. The patient was hospitalized with pneumonia during the first inpatient stay, and the second inpatient hospitalization addressed exacerbated congestive heart failure (CHF). The patient arrived for
Case Study: Readmission Linking for Hospital Stays Reversed Read More »
CLINICAL SUMMARY: A 22-year-old patient, four weeks postpartum, arrived in the emergency department suffering from abdominal pain and nausea. An ultrasound revealed the common bile duct was dilated to 8 mm, and a CT scan showed gallstones. In addition to steatosis, the patient also had a positive Murphy’s sign. Lab tests performed during the patient’s
Case Study: Peer-to-Peer Review of Overlooked Medical Details Can Overturn Denials Read More »
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
Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial Read More »
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
Case Study: Post-Surgery Inpatient Admission Denial Overturned Read More »