Clinical Customizations Win Appeals: First in our “How I Won My Appeal” series

Medical billing professionals work hours developing effective appeal letters. However, often, the success stories which result from this effort go untold. At Appeal Solutions, we love to hear your appeal success stories and now plan to pass them along in an ongoing “How I Won My Appeal” series.

As follows is a successful appeal scenario provided by Christine Henderson, RN, of Scituate, MA. Henderson successfully strengthens her appeal letter templates by adding clinical customizations pertinent to the patient’s highly specific treatment plan. These arguments are often persuasive in getting payers to apply more flexibility to treatment reimbursement guidelines.

By Christine Henderson RN-BC, MSN, CMC, LTCP, LNC, CH Guided Care

One challenge that an institution encounters when sending an appeal for a level of care denial is the use of different admission criteria. The two most utilized criteria for the healthcare system in which I write appeals for are Milliman Care Guidelines and McKesson Interqual. Now, if you happen to be unfamiliar with such criteria, simply, it specifies what criteria will be necessary in determining the level of care for each individual patient (observation versus inpatient). This criteria Is specific to the patient diagnosis, severity of illness and intensity of service. For this short story please keep in mind that the healthcare system where I am employed utilizes McKesson Interqual and this particular denying payor utilizes Milliman Care Guidelines.

What else you should be aware of is my appeal letters are templated but individual information is added to support the inpatient level of care. I typically add a HLOC (hospital level of care) attestation, the McKesson criteria and any written documentation that provides the reader with a clear image of the patient. Keeping that in mind, as nurses we know there is nothing more favorable than actually laying eyes on a patient.

This particular denial involves a 72 year-old female that was admitted to one of our hospitals for syncope. Utilizing McKesson Interqual the patient met inpatient level of care. So, the attending emergency room physician signed the HLOC attestation that the patient would admit for two midnights with a diagnosis of syncope. When the payor reviewed the admission they used Milliman Care Guidelines as this is their criteria and low and behold this patient did not meet inpatient level of care for syncope and approved the event as an observation level of care. Thus, a denial letter was sent and the appeal process began.

As a side note, because syncope can have many causes and often upon discharge the cause may not have been discovered, it creates a true challenge when determining admission level of care.

In this particular case, I was not able to send the documentation that supported this payors’ Milliman Care guidelines but I was able to write a systematic, successive time based letter. I sent documentation that defined the admitting physicians’ rationale for an inpatient level of care. I enclosed the diagnostics ordered and findings. The addition of no significant past medical history was actually valuable because it proved that the patients’ new onset of acute presenting symptoms placed her at risk. Lastly, a comprehensive discharge plan with community physician follow-up, medication reconciliation and teachback from the patient and/or caregivers tied together the inpatient admission nicely.

In conclusion, this successful denial overturn demonstrates that even though institutions may have certain protocols or criteria, that may not align with a payors’ criteria, the power of written documentation that is inclusive and pragmatic can change the outcome of a any denial. Remember, be concise and when writing your appeal, tell the story so that the reader can visually see the patient without actually being there.

If you have a How I Won My Appeal Success Story, please contact Tammy Tipton at

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