Guest post: The literary appeal of appeal letters

by Howard Rodenberg, MD, MPH, CCDS

One of the reasons I’m not a famous writer (well, one of many) is that I’m kind of lazy. I know real writers write every day, for a set amount of time or to complete a specific number of pages or words, so that writing becomes a habit. Instead, I write in fits and starts. Some weeks I’ll have five ideas in my head, and they compete with each other to emerge on the keyboard before the mood passes by; other times months go by when it’s just more fun to binge-watch The First 48. (Which is why I’m pretty sure that if I’m murdered in Tulsa or Mobile, they’ll find the killer. New Orleans, not so much.)

So, when the muse strikes, I try to work quickly. But today I had a realization that I write things for my own amusement all the time. I just put them in my letters of appeal for third-party claims and audit denials.

For example, here’s what I do when the diagnosis is rejected, but there’s no particular rational why:

The reviewer’s note is a hodgepodge of often random and unrelated data that never really communicates why the diagnosis is invalid. The reviewer offers no alternate criteria or standards for the diagnosis, but simply indicates that the code is in error without any supporting information. While the Coding Clinic reference suggests that payers may establish a clinical definition, none is offered here; the audit practice is non-complaint with the reference cited. It’s difficult to understand how ethical business practices allow denial of a code with no rationale offered for its deletion. We would argue that without any clear basis of support for the denial, the denial be rejected. 

When they do have criteria, they’re often wrong. Here’s what I do when they decide that the Kidney Disease International Global Outcomes (KDIGO) says something that it clearly does not:

The reviewer offers no objection to the use of KDIGO criteria as the “gold standard” to establish the diagnosis of acute kidney injury (AKI). Instead, there is an unsupported claim that creatinine must double from baseline in order to establish the diagnosis of AKI in a patient with chronic kidney disease. This is flatly not true. KDIGO does not have different standards for diagnosing AKI in patients with chronic kidney disease (CKD). There is no support for the reviewer’s claim within KDIGO documents. The reviewer again indicates that there is no notation of oliguria or anuria; the uncontested “gold standard” KDIGO criteria does not require either to establish the diagnosis of AKI.

Here’s something similar pertaining to the American Society for Parenteral and Enteral Nutrition (ASPEN) definition of malnutrition:

The reviewer notes that ASPEN criteria are not met. Once again, the reviewer seems to not actually know the criteria cited. Measures of albumin and pre-albumin are not part of the ASPEN criteria and are specifically noted to require “interpretation with caution” within the paper’s narrative as non-specific inflammatory indicators. “Ideal” and “Usual” body weight are not indicators within ASPEN. BMI is similarly not an ASPEN indicator. It’s also of interest to note that the initial denial made a specific note that BMI was not an indicator of malnutrition but is now perfectly happy to use BMI < 16 (patient’s BMI was 15.6) at this time as a positive indicator of severe malnutrition.

Speaking of malnutrition, anyone ever get the excuse that patients can’t be malnourished because they only got oral supplements? Yeah, me too:

Further, the reviewer contends the use of oral supplements is insufficient to support the diagnosis, and that more invasive means of nutritional support should have been used. Clinicians should always use the least invasive means to meet therapeutic goals. In the case of malnutrition, that means would be oral supplements if the patient is able to tolerate an oral diet. Requiring that enteral feedings, TPN, or other invasive interventions be used to address malnutrition subjects patients to potential harm such as risks of aspiration, line infection, and severe electrolyte disturbances, and is unethical in practice. The fact that oral supplements can be used at home does not invalidate their use in the inpatient setting as the preferred and safest means of nutritional supplementation in the patient able to tolerate oral feedings.

Switching gears, this is a phrase I like to use when the payer insists on using Sepsis-3 criteria:

Furthermore, the literature is clear that the use of Sepsis-3 as the definition of sepsis is associated with increased mortality. It would be unethical for an insurance company to encourage clinicians to use diagnostic criteria associated with a higher rate of death.

Here’s a paragraph I’m particularly proud of, to be used when the second or third level of denial doesn’t even acknowledge your previous correspondence:

In our previous correspondence, we replied to each if the reviewer’s points of contention in a complete and comprehensive fashion. The current letter of denial offers no new clinical criteria by which to reject the diagnosis of sepsis, nor restates or reinforces the prior objections. As no rebuttal to our previous response has been offered, we would contend the facts are no longer in dispute and the process should have ended with the audit finding overturned. Prolonging this process is simply an effort to deny payment for care rendered rather than an honest discourse over clinical diagnosis and care.

Or when they switch the reasons for denial on the next go-round:

The current letter takes a different approach, instead raising a new set of issues and asking us to meet a different standard. To now change the basis for the audit finding is patently unfair and can only be seen as simply an attempt to find another way to recoup costs incurrent for patient care rather than engaging in a patient-focused discourse.

Then there’s a note about references I find useful:

Further, the reviewer’s reference is not current. The reviewer uses a 2016 document in support of the denial. This document is no longer valid and has been superseded by [XYZ]. It’s difficult to take an audit seriously when it reflects ignorance of appropriate contemporary references.

And last, when it’s the second or third appeal I always finish with this little piece. Asking the payer to actually tell me who’s making the judgement will likely never happen. But I figure if I’m taking my time to craft a letter and willing to put my signature to it, shouldn’t I be afforded the same courtesy?

Thank you for your time and consideration. At this level of appeal, we would request that the case be reviewed by a specifically identified and appropriately qualified physician. If I can be of any assistance as you consider this matter, please don’t hesitate to contact me.

What are your favorite things to put in a letter of appeal? I look forward to sharing your literary thoughts.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Opinions expressed are those of the author and do not necessarily represent those of ACDIS, HCPro, or any of its subsidiaries