One Claim with Multiple Denials Calls for Smart Defense

CERT claim review highlights need for strategic approach.

How do you handle your appeals when there is more than one issue being denied? For example, if the payer denies both the medical necessity of the level of care as well as the coding of a procedure, what strategies should you employ to challenge it?

When two issues are being denied, the appeal strategy first of all will depend on whether the denials were issued at the same time. If the denials were issued at the same time (that is, within the same decision letter), then both issues should be appealed in the same appeal letter. This typically requires the collaboration of both a clinician and a coder to develop one cohesive response that addresses both issues.

If the two issues were denied at different times (that is, two separate decision letters were issued with different dates), then each issue should be treated as a separate denial with a separate appeal, even if the appeal time frames overlap. The obvious logic behind this is that the time frames for appeal will be different for each denial, depending on the date the denial was issued. Thus, the appeal for each issue should be filed separately so that time frames can be more easily managed.

Just recently I was reviewing a decision letter from the Comprehensive Error Rate Testing (CERT) contractor on the issue of a TAVR – that is, a trans-catheter aortic valve replacement, which is currently on the CMS inpatient-only list.

Essentially, the CERT contractor was reviewing the claim for this nine-day hospital stay to ensure it met the criteria for medical necessity, as outlined in the National Coverage Determination for this procedure. The contractor reviewed the documentation to ascertain whether certain elements, such as the required preoperative evaluation by two cardio-thoracic surgeons, were present in the record. Unfortunately, in this case, the required evaluations were not present, and the CERT denied the medical necessity of the procedure, resulting in down-coding of the DRG.

What I found interesting, though, was that the CERT went to great lengths to explain that the inpatient hospital admission for this inpatient-only procedure was in fact reasonable and medically necessary. The reasoning the CERT provided was that this patient’s intraoperative and postoperative complications included a need for a blood transfusion, BiPAP, monitoring of thrombocytopenia, and treatment of increased blood pressures.

So let’s imagine for a moment that the CERT contractor reviewed the medical necessity of a procedure that was not on the inpatient-only list. And let’s imagine that in this case, the patient experienced complications that warranted an inpatient admission, following the two-midnight rule. And let’s further imagine that in its decision letter following its review, the contractor issued a statement on the medical necessity of the inpatient admission, deeming it to be reasonable and medically necessary.

I would strongly encourage a provider to flag a case such as this as having been reviewed and approved for the appropriate level of care, even if that was not the original purpose of the review. Should this case ever be requested by any other CMS auditor for level-of-care review, I would certainly argue that it is no longer eligible.

And finally, I would be certain to reiterate in my appeal of the medical necessity of the procedure that the CERT contractor had deemed the inpatient admission to be reasonable and medically necessary.

The CERT denial letter and your appeal letter will serve as proof that this case was already reviewed for level of care, should any other CMS auditor attempt to pull it for review.