gram negative pna denial

smarko@cortlandregional.org

I just received my first denial on gram negative pneumonia.  The insurance co. is quoting criteria dated 2005.  Is anyone else seeing this?  I am trying to get my providers to identify more clearly, what they are treating.  

smarko@cortlandregional.org

kshumpert

I haven't seen that.  Most typically our denials for gram negative pneumonia the auditors cite that there is no sputum culture.  We still appeal.

whitneyarellano

We have also been seeing quite a few gram negative pneumonia denials. They don't always list the criteria they use, and when they do, it's often outdated or not accurate (such as lack of sputum culture). I even had one where the patient had a sputum culture come back positive for a gram negative organism and that was documented and they wanted to deny the entire diagnosis of pneumonia. It's ridiculous. My thoughts are, if they shotgun their denials, we should shotgun our appeals. So if there is any criteria that even mildly supports a diagnosis that is being denied, I recommend appeal.

vparent@emhs.org

Look for reference articles (current) that support your viewpoint. I would advise giving your physician a heads up about the denial and express a written statement from the physician or request a peer to peer discussion.