Carefully crafted appeal letter provides results

(Editor’s note: Dan Wassilchalk, director of performance improvement and utilization management at Johns Hopkins Hospital in Baltimore, described how his facility dramatically increased its recovery rate on denied days in the February 2002 issue of Hospital Access Management. In response to a request from readers, he shares below an example of an appeal letter sent by his department.)

ATTN: Medical Affairs Appeals Department
4 Taft Court
Rockville, MD
RE: [Patient’s name]
JHH#
MEMBER ID#
DOS: 12/14-12/17/01

Dear Sir or Madam:

The case of the above patient is being appealed for the denial of 12/16/01. After review of the medical record, it was noted that this 59-year-old with a history of cervical disc disease and multiple surgical interventions, including cervical disc surgery in 1995 and lumbar disc surgery in 1984 and 1994, was admitted after he developed pain in the lower extremity that progressed to the thigh and caused numbness and burning in the foot. Walking, bending, and lifting exacerbated the situation. An MRI was positive for an L4-5 lateral disc on the right and L5-91 disc disease.

An MRI revealed C4-5 and 5-6 effusion and C4 stenosis due to a herniated disc and calcification of his ligament. There also is a small disc at C2-3 and C6-7. He underwent a C3-5 laminectomy with effusion and instrumentation on the 14th. He recovered in the neuro unit and was transferred to the floor on the 15th. On 12/15, his white blood count (WBC) was 8.4. On 12/16, it spiked to 15.9, which required additional observation. Also, on the day in query, he was undergoing physical therapy and receiving education regarding spinal surgery. On 12/17, his WBC had decreased to 11.4 and he was afebrile. It was determined that he was stable for release. Please reconsider the denied day, as this patient could not be released with an elevated WBC.

Enclosed for your review is a copy of the patient’s medical records. Please direct your written response to my attention within 45 days of this letter at the above address. Thank you.

Sincerely,

Daniel Wassilchalk, MHA, RRA, Director
Department of Performance Improvement/Utilization Management