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 U/L), and a CT of the abdomen/pelvis demonstrating mild peripancreatic inflammatory changes consistent with acute pancreatitis. The patient’s medical history included hypertension, anxiety and depression, GERD, and alcohol use. Doctors treated the patient conservatively with bowel rest, IV fluids, pain management and antiemetics. The patient was discharged the following day after tolerating a clear liquid diet and improvement of symptoms.
DENIED INPATIENT STAY
The patient was admitted with inpatient status due to acute pancreatitis, however, the insurance company denied the inpatient admission due to a “medical standard” denial despite the medical reasons for inpatient admission documented by the attending physician. Within 24 hours, AppriseMD scheduled a peer-to-peer with the insurance company to discuss the specifics of the case.
THE APPRISEMD PROCESS
An AppriseMD physician advisor, acting on behalf of the attending physician, completed a peer-to-peer discussion of the case with the insurance company medical director. The AppriseMD physician advisor communicated the medical reasons justifying inpatient level of care for the short length of stay, just one day, which resulted in the denial being overturned. The physician advisor was able to gain approval for the inpatient stay by discussing the patient’s medical complexity including the use of the IV opioids and close monitoring. This, paired with a lipase greater than 10 times the baseline, compounded with positive CT findings and a history and physical exam consistent with acute pancreatitis, led to the reversal of the insurance company’s initial decision to deny the inpatient admission.
This case highlights the benefits that physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.