Are institutions appealing Sepsis as PDx if the patient meets Sepsis 2 / Super SIRS,  but not SOFA? We have one hospital in our system that uses only Sepsis 2 as their criteria, and many of them have been denied - I have appealed many but so far most have been upheld

. Do I have a leg to stand on? Any luck out there?



  • Will need some more information to be helpful. What Payer are you getting the majority of denials from? Are all of those denials regarding a lack of organ failure? Do they specifically reference Sep-3? How many times are you appealing? Are you getting to P2P?

  • edited October 29

    UHC, yes due to the lack of "remote" organ failure, even though they do have organ failure. Sepsis -3 is always referenced. I have appealed 2 to the final level and am awaiting peer to peer the others I have not.

    I have read the article that they reference (attached here)! no where in the article does it state that the patient's organ failure must me remote from the infection.

  • Yes that is UHCs favorite denial, for us anyway. I have a fairly standard template I use to appeal the "remote organ failure" argument. And I just keep sending the same appeal until I win or they say I can't send anymore. I have won a couple that way. They technically do not have a leg to stand on with the "remote organ failure" argument so I recommend going to P2P as much as possible.

    That being said, in general when a patient has something like sepsis with pneumonia and acute respiratory failure, or sepsis with pyelonephritis and AKI, I ask the provider if they feel this is organ dysfunction beyond what would be expected in the normal disease process.

    As an aside, we currently don't have a P2P process for UHC; do you all? We are hoping to get it worked into our next contract.

    Regarding sepsis 2 vs. sepsis 3 - I do not bring up criteria at all with the docs, (I'm sure that's not what you were implying, just being specific) but I am working on an education campaign to focus on having the docs document sepsis with or without organ failure and then we let the cards fall where they may.

    Does that help at all?

    Email me anytime

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