Medical Necessity

Doctor visits patient post-surgery in the hospital.

Case Study: Post-Surgery Inpatient Admission Denial Overturned

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

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 […]

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Physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.

Case Study: Medical Necessity Behind Short Stay is Key

Case Study, Denial Management / By

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

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