Sepsis: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospital inpatient services. California Health and Safety Code § 1317.1, subdivision (a)(1), defines “emergency services and care” as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) two physical therapy evaluations, (2) eight physical therapy visits, (3) eight LVN visits, and (4) two skilled services evaluations by a registered nurse. Findings: The physician reviewer found that Bowles and colleagues report that risk factors for poor outcomes and rehospitalization in sepsis survivors may include septic shock and associated acute organ system dysfunction. Prescott and Angus note that early hospital care for sepsis focuses on prompt recognition, treatment with broad-spectrum antibiotics, elimination of infectious sources, and resuscitation with intravenous fluids and vasopressors when appropriate. In this case, the records indicate that the patient was hospitalized with sepsis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 60-year-old female with a history of chronic obstructive pulmonary disease (COPD), lung cancer, chronic kidney disease, and chronic liver failure who presented to the hospital for upper gastrointestinal bleeding, sepsis with hypoxemic respiratory failure from pneumonia and possible congestive heart failure with severe lactic acidosis. The patient was initially hospitalized in the intensive care unit (ICU) and was intubated and sedated. She was treated with intravenous (IV) antibiotics and was also noted to have worsening renal failure initially requiring continuous renal replacement therapy (CRRT) then hemodialysis (HD). She was also treated for clostridium difficile infection.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued inpatient hospitalization. The records provided for review document that this patient was admitted to the hospital with confusion and possible sepsis. He continues to receive IV antibiotics for discitis of L4-5 and possible C4-5. His confusion was determined to be due to hepatic encephalopathy with delirium and weakness. At the time of admission, it was unclear if the patient had ongoing sepsis due to the discitis or another cause. The providers recommended continuing the patient on IV Cefazolin for six additional weeks. He did not have any active bleeding but was persistently anemic and therefore received a transfusion of one unit of blood. The patient’s white blood count was normal and there were no significant electrolyte disturbances.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for sepsis was denied, the published record says the denial is worth fighting.