Using Evidence-Based Guidelines to Win Appeals

By Denise Wilson | October 29, 2019

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 or service. It’s one of the fundamental but probably the most crucial 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 see clear evidence of the physician’s reasons for admission or treatment in the record. Auditors may be looking for the expectation of greater than two 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. How well can that be accomplished when the appeal writer very often does not have access to the treating physician’s decision-making process? It’s not as if an appeal writer and the treating physician have time to sit down together and discuss each denied case in detail. The writer does not have the luxury of interviewing each treating physician on their medical decision making for each patient encounter that was denied payment.

An appeal writer could guess as to why a physician made the medical decisions he or she did. But, that would just be speculation and would likely not hold up well in a court of appeal. However, if the documentation in the medical record supports that the medical care provided to the patient is equivalent to the current standard of care in the medical community (at the time the care was provided), then the payer should pay for that care.  The payer should reimburse the provider for care in the manner in which it was provided, whether that be in an inpatient or outpatient setting or for a procedure or service.

Providing care according to acceptable standards of practice is the basis of every payer’s definition of appropriate medical care covered under a payer’s insurance plan. Thus, it has to serve as a foundation of medical necessity appeal arguments. EBGs provide the support for that standard of care and should be incorporated appropriately in every medical necessity appeal argument.

[1] IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press. https://doi.org/10.17226/13058