Denial Management

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 […]

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

Blood work for DKA testing

Case Study: Short Stay Common Diabetic Ketoacidosis Denial Overturned

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

Can hospitals receive full inpatient admission reimbursement for a patient experiencing diabetic ketoacidosis who only spends one night in the hospital? AppriseMD’s latest case study shows that it is possible. A young adult patient with type 1 diabetes struggling with consistent vomiting over two weeks stayed one night as a hospital inpatient, but commercial insurance

Case Study: Short Stay Common Diabetic Ketoacidosis Denial Overturned Read More »

Doctor walking down hallwya with clipboard

Case Study: Post-Operative Pulmonary Embolism Inpatient Denial Overturned

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

Medical necessity often requires nuanced interpretations based on an individual’s medical history that considers appropriate, reasonable and necessary healthcare interventions. While insurance companies typically utilize a finite criterion that meets medical necessity, physician advisors are indispensable for safeguarding reimbursement to ensure that healthcare organizations can continue providing quality care. Continue reading to see how AppriseMD

Case Study: Post-Operative Pulmonary Embolism Inpatient Denial Overturned Read More »

Empty hospital bed

Case Study: AMA Inpatient Denial Overturned

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

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,

Case Study: AMA Inpatient Denial Overturned Read More »

AppriseMD’s latest case study centers on a patient that was hospitalized for chest pain, and the claim was denied based on unproven medical necessity and a lack of reasonable expectation of hospitalization that crossed two midnights.

Case Study: Medical Necessity and Reasonable Expectations

Case Study, Denial Management, Medical Necessity, Peer-to-Peer, Two-Midnight Rule / By

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 »

PA secondary reviews raise reimbursement

Case Study: Physician Advisor Secondary Review Insight on MA Case

Case Study, Denial Management, Medicare, Two-Midnight Rule / By

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 »

CMS IPO 2024

Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay

Case Study, Denial Management, Inpatient Only List, Medicare / By

AppriseMD physician advisors overturned a denied inpatient stay for a myomectomy by discussing this procedure’s placement on the inpatient-only IPO list, which is for surgeries that are considered high risk. Even though the patient was discharged on the day of surgery, this reversal shows the importance of peer-to-peer discussions conducted by physician advisors with regulatory

Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay Read More »

Patient being treated in the hospital

Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission

Case Study, Denial Management / By

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 »

Overnight short-stay denial reversed in AppriseMD case study.

Case Study: Overnight Short-Stay Denial Reversed

Case Study, Denial Management, Length of Stay, Peer-to-Peer / By

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 »

Scroll to Top