In the complex environment of revenue cycle management, clinical denials for medically necessary services can significantly impact reimbursement – especially in high-acuity cases. This case study highlights how Managed Resources successfully overturned a critical care denial for a high-risk ICU patient, securing a reimbursement of $128,607.70.
Faced with a payer rejection citing non-compliance with narrowly defined criteria, our expert Clinical Appeals team deployed a detailed, evidence-based strategy grounded in clinical judgment, regulatory guidance, and payer policy alignment. The result: a complete reversal of the denial and full payment for services rendered.
Challenges
A 66-year old undomiciled male with significant cardiac/vascular history coronary artery disease (CAD), Congestive Heart Failure, Cardiomyopathy, Cerebral Vascular Accident, and Myocardial Infarction) presented to the ED after a witnessed cardiac arrest. Admitted to ICU for Ventricular Fibrillation, Acute Respiratory Failure, Pneumonitis, and post Cardiac Arrest. He received medical management with tentative plan for coronary angiography and possible ICD placement (found to have EF of 15-20%).
On day 4, he was transferred to DOU level of care for continued management and underwent a Selective Bilateral Angiography Left Ventricular Pressure and Ventriculography, and Abdominal Aortogram with findings of severe CAD. Per Physician judgment, revascularization of the fibrosed LAD territory would be “futile” due to current lesion correlated with the ostial RCA stenosis, PCI/DES with Hemodynamic support via Impella was recommended.
Subsequently, a selective coronary angiography, temporary pacemaker placement, Impella hemodynamic support catheter placement, intravascular ultrasound imaging IVUS of RCA, coronary orbital atherectomy of proximal RCA, Coronary angioplasty and DES in proximal RCA was performed on day 9 of the stay in preparation for angioplasty and stent. The following day, a Placement of a Single Chamber Cardio Defibrillator Implant was successfully performed with discharge on day 11.
Our client submitted first level of appeal, and was upheld due to procedure code 5A0221D not meeting the associated diagnosis code relationship criteria for CMS ID9s A52966. Although this did not meet this criteria, client requested a second level appeal by Managed Resources. Per payer medical policy, the procedure was considered medically necessary only in 3 life threatening situations: (1) Cardiogenic shock, (2) severe decompensated heart failure with threatening multi-organ failure, or (3) complications/disturbances of the circulatory system intra-operatively or postoperatively. In this case – none of the criteria were met.
Solution
As part of Managed Resources’ industry-leading clinical appeals process, the denial was reviewed and assigned to a specialized RN to begin the appeal process.
The appeal contained a brief summary of the patient’s history and clinical presentation with medical necessity supporting appropriate treatment of Ventricular Fibrillation, Acute Respiratory Failure, Pneumonitis, and post Cardiac Arrest. Additionally, significant Physician documentation was referenced to support diagnoses, diagnostics, use of Impella to provide optimal outcome, and treatments/treatment plan.
The appeal included Physician Judgment per CMS admission guidelines, MCG criteria for Ventricular Arrhythmia, EMTALA, CMS Two Midnight Rule, Payer medical policy for physician judgement, Physician Advisor Review supporting decision for Impella procedure, and medical literature stating Impella was underutilized, appropriateness for high-risk patients, and safe/cost effectiveness.
Results
The appeal emphasized the high-risk clinical presentation of the patient with supporting Physician judgment for the most appropriate treatment, despite not meeting payer criteria.
Client submitted first level of appeal and was upheld. Denial was overturned with reimbursement for all denied dates of service for $128,607.70.
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