Using Evidence Based Guidelines to Win Appeals

The inclusion of evidence based guidelines (EBGs) is imperative in appeal writing involving medical necessity denials, including level of care or medical necessity of a procedure. It’s one of the fundamentals but probably the most important aspect of appeal writing. Why is that?

Foundation of Sound Medicine

Evidence based guidelines are the foundation of sound medicine. The Institute of Medicine defines clinical practice guidelines as such: “Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”[1]

Practicing physicians use EBGs or clinical practice guidelines along with their own experiences and patient preferences to determine the best course of treatment for an individual patient. Unfortunately for the recipients of payer audits, documentation of the physician’s incorporation of EBGs into his clinical decision making very often does not make it into the clinical record. Payer auditors want to read a very clear description of the physician’s reasons for admission or treatment in the record, such as expectation of greater than 2 midnights of care, risks of adverse events, clear indications for the need for the surgical procedure and risks to health if the procedure isn’t performed at this time, etc.

Connecting the Dots

When such documentation is lacking in the medical record, the savvy appeal writer will use EBGs to connect the dots between the documentation in the medical record and the standard of care in the medical community. When I teach this concept in appeal writing, some clinicians will say, “What? How can I do that? I can’t write what the doctor was thinking when he made his decision to treat the patient. Only the doctor knows that.” Well, let me tell you how this works.

Of course you can’t know what the doctor was thinking at the time. We as humans currently do not have the ability to be inside someone’s head and know their thoughts. However, if the documentation in the medical record supports that the medical care provided to the patient is commensurate with the current standard of care in the medical community (at the time the care was provided), then the payer should pay for that care in the manner in which it was provided – inpatient, outpatient, dual-chamber pacemaker versus single-chamber pacemaker.

Providing care according to acceptable standards of practice is the basis of every payer’s definition of appropriate medical care that is covered under a payer’s insurance plan. Thus, it has to serve as a foundation of medical necessity appeal arguments and EBGs provide the support for that standard of care. How are you incorporating EBGs in your appeal arguments?

[1] Graham, R. (2011). Clinical practice guidelines we can trust. Washington, D.C.: National Academies Press.