Appeals considerations are conducted by health professionals who:
- Are clinical peers;
- Hold an active, unrestricted license to practice medicine or a health profession;
- Are board-certified (if applicable) by:
- A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or
- The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine);
- Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and
- Are neither the individual who made the original non-certification, nor the subordinate of such an individual.
Question: If new information is received with an appeal request, can a nurse reviewer approve the appeal if the new information meets criteria?
Response: Yes. Though this process is not specifically addressed in the accreditation guide, it is not prohibited by the standards. An organization must meet the timeframes required by the standards regardless of any additional steps it may conduct.
Question: What is appropriate specialty matching and does the standard of care in a community factor in? For instance, in our community we have no endocrinologists so our PCPs generally care for their own diabetic patients, but if that patient is in a teaching facility they might be cared for by an Endo. If there is an appeal by a specialist for a condition, which is generally treated locally by a PCP, who would URAC like to see reviewing the appeal?
Response: When selecting a physician to conduct a medical necessity appeal, first choice would be a specialist in the area of concern for the appeal, even if the physician requesting the appeal is not a specialist. Physicians with more general practices (e.g., IM, PCP, FP, etc.) may conduct an appeal if they have experience treating the case under review. When asked to do a review, physicians will tell you if it is not an area they typically treat, in which case you would select another physician to conduct the appeal. Also, pursuant to the standard, the selected appeal reviewer is “…mutually deemed appropriate” by your organization and the physician requesting the appeal [HUM 32(d)]. So if there is some doubt, it is perfectly acceptable to discuss the selection with the requesting provider. Also, general practitioners are not used for appeals and it is not appropriate to have a pediatrician review an adult case.
If an endocrinologist or a PCP is managing a diabetic case and has made an appeal, then an endocrinologist would be first choice to conduct the appeal, an IM or PCP with extensive experience in diabetes would be a second choice. See additional scenarios below.
Scenario 2: Cardiothoracic surgeon performs CABG, patient is newly diagnosed with Diabetes, Endo was consulted and discharge left up to Endo. Last day was denied and is being appealed. What kind of specialist should review? Endo, IM, FP or GP or Cardiothoracic surgeon?
Response: The issue keeping the patient in the hospital was diabetes, so an endocrinologist would review the appeal for the last day of inpatient stay, or IM/FP with extensive experience in diabetes. General practitioners are typically not used for appeals.
Scenario 3: Pt. was admitted for Chest pain by IM/GP/FP. Cardiology was consulted. Discharge by attending left up to consultant. Day denied and appealed. Who reviews, Cardiology or IM/ FP/GP?
Response: Medical issue could be reviewed by IM/FP or a cardiologist. General practitioners are typically not used for appeals.
Scenario 4: Pt admitted with new onset of seizures by IM/FP/GP/Peds. Neuro consult ordered. Discharge by attending left up to consultant. Day denied and appealed. Who reviews, Neuro or IM/FP/GP/Peds?
Response: Neurologist would conduct the appeal since seizures were the reason for the last inpatient day. If it was a pediatric patient with seizures, then a pediatrician with experience treating those types of patients could conduct the appeal.
Scenario 5: Can FP review for IM for inpatient appeals or does it have to be IM for IM and FP for FP, etc.
Response: Internal Medicine should review for Internal Medicine, FP for FP.
Scenario 6: Does the matching have to be MD to MD or can it be MD reviewed by DO, etc?
Response: MD and DO can review for each other.
Scenario 7: Can a general surgeon review a case of a Vascular surgeon?
Response: Did the appeal turn on a vascular issue – such as was the vascular surgery necessary? If yes, then a vascular surgeon would be appropriate to conduct the appeal. If more of a general surgical issue, then a general surgeon could review the case.
Scenario 8: Do the reviewers just have to have knowledge in the field or truly be "specialty matched"?
Response: Start with the specialty match – you can’t go wrong there. Then there are general surgeons and internal medicine where they may have extensive experience in a given area, and as such could be used for the appeal.
Scenario 9: IM admits for DVT. An inpatient day is denied. Who can review the appeal? FP or Peds or does it have to be IM?
Response: IM would be best choice; PCP/FP could be used. Most primary care doctors will tell you if they do not believe they have the background or experience to review a case. Peds is not a good choice for adult cases.
Scenario 10: FP admits an adult with Pneumonia. Day is denied. Can a Pediatrician review? Must it be FP? IM?
Response: Pediatrician is not appropriate for an appeal on an adult case. FP or IM could review the case.
Scenario 11: A 10-wk pregnant patient admitted with DVT by OB. Vascular surgeon consults and follows, too. Who can review case for denied days? Can FP or Pediatrician review concurrently without consulting with a Like Specialist for advice?
Response: It depends upon the reason for the denial and why patient was kept – was there some other reason for the hospital stay? If it was determined that the DVT condition no longer warranted inpatient stay, then a vascular surgeon, IM or FP could review. If there was some other complication related to the pregnancy, then an OB would appear to be appropriate.
Scenario 12: Total abdominal hysterectomy performed by GYN surgeon. Can general surgeon do the appeal review?
Response: If the general surgeon has experience with abdominal hysterectomies, then yes.
Scenario 13: Pulmonologist admits for pulmonary emboli. Who must review appeal? IM, FP, Peds or pulmonologist?
Response: Pulmonologist, IM or FP. Peds should review for pediatric patients.
Scenario 14: Pancreatitis admitted by FP. Consulted with a general surgeon, but treated medically. Who should review appeal?
Response: IM or FP.
Scenario 15: GI hemorrhage admitted by GE. No surgery was required, just scoping and watching. Who should review appeal? GE, surgeon, IM, FP, Peds?
Response: GE, surgeon or IM. FP if experience with these types of cases. Peds should not review adult cases.
Scenario 16: Can a Pediatrician review cases on adults that were admitted by IM or FP or specialists? Can FP do reviews on neonates being cared for by neonatologists?
: No to both scenarios.