Even with concerns about days spent waiting on a transfer to a higher level of care, an insurance company medical director reversed an inpatient stay denial after a Peer-to-Peer discussion of the case. CLINICAL SUMMARY: Type 2 Diabetes and Chronic Kidney Disease A 40-year-old patient arrived in the Emergency Department complaining of worsening right upper […]
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On a daily basis, hospitals must wrestle with denials for inpatient level of care for patients. An AppriseMD case review physician recently had a successful inpatient denial overturned after completing a Peer-to-Peer with an insurance company medical director regarding a case that involved a patient with asthma and a high BMI. CLINICAL SUMMARY: Asthma and
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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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A one-day inpatient stay for an elderly patient with a CHADS score of 4 and low EF percentage was overturned after the hospital level of care was discussed in detail during a Peer-to-Peer with the insurance company. The insurance company initially recommended an observation level of care without much explanation, but its physician overturned that
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