Med Surg denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient hospitalization for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. According to article researchers regarding care of postoperative cystic fibrosis (CF) patients “Postoperative pain management is critically important in the CF patient population. Pain control is especially important in patients with CF to encourage coughing, deep breathing, and minimize pulmonary complications. Patients should have early access to chest physical therapy and early activity and mobilization as well.

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for intraoperative neurophysiologic monitoring. Peripheral nerve injury is a serious complication of hip surgery that can adversely affect a patient’s health outcome. Several studies have described the use of electromyography and intraoperative sensory evoked potentials for early warning of nerve injury. In the medical literature, analyzed data collected between 2001 and 2010 from 69 patients who underwent complex hip surgery by a single surgeon using multimodal intraoperative monitoring. The authors reported that in 35% of the procedures, the provider was alerted to a possible lesion to the sciatic or femoral nerve. The authors concluded that intraoperative neurophysiological monitoring is effective for alerting the surgeon to the possibility of nerve injury.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Long-term acute care hospital (LTACH) services. LTACH level care is intended for patients who require care that is more medically complex than can be provided at lower levels of care, such as inpatient rehabilitation, or SNF levels of care. LTACH level of care includes provision of chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care, ventilator weaning, and frequent imaging and laboratory testing. In general, more than one of these treatments is being provided at the LTACH level of care.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient medical/surgical treatment. The records provided for review document that this patient’s wound care has required the use of a wound VAC that is changed every three days. He is also receiving three parental antibiotics that will be ongoing until six to eight weeks after the wound closes. He requires skilled physical and occupational therapy for activities of daily living and a Clinitron bed. He is non-weight bearing on the left lower extremity. Documentation shows an improving wound bed without evidence of acute infection or exposed bone. The provider’s progress notes indicate that the patient has been afebrile and hemodynamically stable. He is tolerating oral analgesics and oral nutrition without complications.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Med Surgwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.