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 […]
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
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 »
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 »
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 »
CLINICAL SUMMARY: A previously healthy six-year-old boy arrived in the emergency department with chest pains and a high heart rate of 240 bpm. Upon arrival, he was hemodynamically stable and had no mental status changes. The symptoms began during an evening soccer practice and continued once he was at home. His mother, who has a
Case Study: Pediatric Short Stay Denial Reversed Read More »
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: 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 »