Premature, CNS Malformation, 4mo.

Submitted by Denise M. Goodman, MD, MS
Medical Director of Case Management and Care Coordination/Physician Advisor, Ann & Robert H. Lurie Children’s Hospital of Chicago  

Denial Type: Lack of Clinical Information
Insurance: Not Supplied
Length of Stay: N/A
Reason for Being Hospitalized: 4 mo former premature infant (27 week gestation) with a CNS malformation, spasticity, and inability to extubate. Transfer from an outside hospital.
Pertinent Past Medical or Maternal History: Premature infant, 27 week gestion, now 4 months old (corrected gestational age 43 weeks) with a CNS malformation, spasticity, and inability to extubate.

Hospital Course:

The patient was transferred to our hospital at midday and we confirmed coverage and notified the payer that same day. We faxed clinical information on Hospital Day 1 and 3 and followed up with further information on HD 7, 9, 11, 14, 16, 21. Despite this transmission of information a denial for “lack of clinical information” was issued.

Appeal Strategy:

We were able to refute the payer’s contention with documentation of our adherence to their requirement for regular clinical updates. We attached the fax confirmations with the appeal letter detailing these dates. Also ensure that your case management team sends actual progress notes from the provider. The appeal letter also included a clinical summary.