Appealing the Dual Diagnoses Dilemma

If patients suffered one illness or injury at a time, healthcare would be simplified. Most patients present a more complicated mix with multiple medical issues requiring treatment. Yet, carrier clinical review criteria and guidelines do not readily account for multiple diagnoses patients.
Denials related to medical necessity, length of stay and/or beyond the specified treatment cap related to number of visits or interventions often require medical records documentation which justifies the care above the standard of care. Frequently, the culprit in such scenarios is that the treatment plan was impacted by a secondary diagnosis. However, the carrier may have been looking only at the primary diagnosis during prior authorization or claim review. Appeals related to such denials should demand a more thorough review of how the secondary diagnoses affected the treatment plan. The following wording can be used to make this request:

It is our understanding that your denial did not involve an in-depth review of the patient’s medical record which documents treatment goals for two separate medical conditions. Instead, benefit availability appears to be based on internally developed or published clinical review criteria related to the primary diagnosis only. It is our position that any clinical guideline used for treatment assessment must address the impact of secondary diagnoses.. Medical guidelines employed for medical decision-making must be flexible and allow for deviations from the guideline in order to incorporate the patient’s unique medical factors. Specifically, the following patient specific variables should be addressed by the guideline and alternative treatment options discussed to make the criteria appropriate for the following: (list patient-specific variables such as patient’s age, comorbidities, treatment history, treatment compliance records, potential side effects, etc) Because there are so many patient-specific variables to assess, it is our position that the treating physician is in the best position to develop a dual diagnoses treatment plan and has addressed these patient-specific variables.