Mary San Juan Hospital Case Study

Mary San Juan Hospital is in receipt of a denial letter dated December 26, 2016 for acute inpatient care provided on the above dates. The denial is based on the premise that it was medically unnecessary. However, the hospital has determined that this acute inpatient admission was warranted and supported by clinical documentation in the medical chart. The treating physician exercised their expert opinion in electing to admit this patient out of concern that his symptoms were attributed to an acute or escalating clinical condition. We are formally appealing this denial of payment for services provided to Mr. M. This patient is a 75-year-old male who required inpatient hospitalization due to: brought by EMS on a gurney via ambulance into the Emergency Department status post ground level fall on the street while chasing his dog and landed through the …show more content…
M was admitted to the surgical intensive care unit of the hospital due to left-sided rib fractures 4 through 8 secondary to ground fall. During hospitalization, he seemed confused at times and was started on IV hydration due to an elevated creatinine of 2.1. And after sometimes, he experienced urinary retention with 800 mL of urine in his bladder, for which a Foley catheter was replaced. On day of discharge, He complained of pain and oxycodone was increased him to every 4 hours instead of 6 on his. He continues to work with physical therapy and required additional therapy at a skilled nursing facility. Once the Mr. M is cleared from the skilled nursing facility he can return home and begin his regular medication regimen. As indicated above, Mr. M was appropriately admitted on an inpatient basis for the urgent management of that could not be managed in an outpatient setting. It is clear that inpatient admission for this vulnerable patient was appropriate and resulted in his favorable outcome after six days of complex inpatient treatment. Only after treatment was he deemed appropriate for