Appealing Clinical Validation Denials in the Era of Sepsis-3

Higher overturn rates noted when the appeal is filed outside of the payer’s internal appeal process. 

I’d like to share some information gained from appealing over 2,000 clinical validation denials for sepsis in the state of New York since the time of the release of the Sepsis-3 criteria in February 2016.

Many of the commercial and managed care payer denials we have received from our clients in New York have been issued by a third-party contractor, not by the payer themselves. Most of these third-party contractors are using, but not specifically quoting or citing, Sepsis-3 criteria in their audits.

The denial language almost always includes some phrasing about the lack of evidence of acute organ dysfunction or end-organ compromise. Occasionally, the third-party contractors will mention Sequential Organ Failure Assessment (SOFA) scores, but without any specific citing of the SOFA criteria.

So, when UnitedHealthcare (UHC) stated in October 2018 that it would be using Sepsis-3 criteria in its audits, I viewed it as just a formalization of the process they were already following. Then, on Jan. 15, the Healthcare Association of New York (HANY) told providers that New York would not use the UnitedHealthcare  Sepsis-3 criteria when reviewing claims to validate sepsis for payment. And the Greater New York Healthcare Association (GNYHA) confirmed that UHC stated that it would not implement Sepsis-3 criteria in the state of New York. It will be interesting to see how or if UHC’s auditing process changes after the response from the Greater New York Healthcare Association.

New York is a state that allows for clinical validation denials to be taken to external review once the commercial payer’s internal appeal process has been exhausted. Some states view clinical validation denials as payment disputes and allow for external review when the medical necessity of the services provided is in question, but not for actual payment disputes. We have experienced higher overturn rates when the appeal is filed outside of the payer’s internal appeal process, but not all states allow that.

We have found that having the opportunity to appeal to an IRE (Independent Review Entity, or agency) in the state of New York has contributed to a higher success rate of achieving overturned denials than for providers in other states that do not offer the opportunity to appeal to an external agency. If your state allows clinical validation denials to be appealed to an IRE, you should be taking advantage of that.

From our experience, when reviewing sepsis denials, the IREs are looking for consistent physician documentation in the medical record establishing the clinical evidence by which sepsis was diagnosed and treated. The IREs are not quoting Sepsis-3 criteria per se, but they are looking for organ dysfunction caused by a dysregulated host response to infection. In order to pass muster for the IREs, there should be documentation that the conditions identified in the medical record required continuous treatment, evaluation, and monitoring, and that the identified abnormal clinical values were attributed to the sepsis by the physicians caring for the patient. The abnormal clinical values don’t necessarily have to be limited to those described in the SOFA criteria, as long as the abnormal values are indicative of organ dysfunction. The physician’s documentation has to make that connection that the abnormal clinical values that support the organ dysfunction are a result of the sepsis. A clearly documented correlation between organ dysfunction and sepsis will very often result in an overturn of a clinical validation sepsis denial.

At least that has been our experience.

Facebook
Twitter
LinkedIn

Denise Wilson MS, RN, RRT

Denise Wilson is a Senior Vice President at AppealMasters and serves as President of the Association for Healthcare Denial and Appeal Management (AHDAM). She also provides ongoing education and expert knowledge to internal and external clients on commercial and Medicare denials and appeals via web-based seminars, onsite training, written materials and one-on-one consultations. She created and trained an appeal-writing team, which has grown to a staff of more than 70 nurses, physicians and coders.

Related Stories

A Policy Shift Impacting Medical Coding in Healthcare

A Policy Shift Impacting Medical Coding in Healthcare

A recent executive order from President Donald J. Trump has introduced potential shifts in healthcare policy, raising questions about insurance coverage, medical coding, and compliance

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24