Guest post: Imaginary backstories for denials

by Howard Rodenberg, MD, MPH, CCDS

As I approach the autumn of my years and the most-significant-other Beloved Dental Empress remains perpetually in spring, she and I sometimes speculate on our life choices. Among these are our decisions to enter the field of healthcare. While being a physician has been a nice ride, I really would have preferred to be an astronaut. For her part, she thinks she should have been a spy. I think she’s right. Whoever suspects the tall blonde with the southern accent of hoarding plutonium? She’s also really good at finding things out on the internet, and she’s proficient with both knives and firearms.

She’s also good at making things up, like cover stories. One of our favorite games is to look around a restaurant or bar and come up with back stories for the couples we see, and the more asymmetric the couple, the better. She’s the one with the stories; I’m the one ordering the adult beverages that fuel the flights of fancy.

You know who else is really good at making stuff up? Private payers. I don’t think I’ve made any secret of my disdain for clinical validation, a process of systematic disrespect for patients and their physicians, a game within a game with rules that make sure we can’t ever win. 

But if you’re an insurance company, and you make the rules, the least you should do is follow them yourself. This is especially true if you’ve already ensured your own success. Why add a second layer of deceit to a rigged contest?

Which brings us to issues concerning acute kidney injury (AKI), sepsis, and malnutrition. I do understand that sometimes there can be honest clinical differences of opinion about how a diagnosis is made and what criteria are used to support such a diagnosis. There can be conflicts within the supporting literature, conflicts between the literature and clinical practice, and conflicts in local standards of care. Even though I believe the entire process of clinical validation of claims to be an example of wrong-headed thought; if you’re going to do it, do so fairly. There’s no reason to perpetuate blatant falsehoods simply to reinforce your denial.

Let’s take AKI. When I’m dealing with a denial for AKI, I usually refute it using an institutional definition built on the Kidney Disease Improving Global Outcomes (KDIGO) definition. But I’m seeing denials stating that KDIGO has specific criteria for the diagnosis of AKI in the presence of chronic kidney disease (CKD). Often the rise in creatinine is “required” to be 1.5 to two times a baseline value in order to validate the diagnosis.

There’s a significant problem here. KDIGO never addresses the rise in creatinine required to diagnose AKI in the patient with CKD. It’s simply a lie to say that it does. KDIGO does establish stages of AKI based on changes in renal function, and does cautiously introduce a role for clinical judgement in the diagnosis, but nowhere in the paper nor its supporting documents, does it state that there are different criteria for the diagnosis of AKI in CKD.

There are two other falsehoods percolating through Denial World. I recently had a sepsis denial stating that part of the reason for the denial was that the patient’s blood cultures were negative. For the record, neither Sepsis-2 nor Sepsis-3 criteria requires positive blood cultures, and work has shown that more than 40% of patients diagnosed with sepsis may be culture-negative.

Similarly, we’ve been seeing malnutrition cases denied because the patient received only oral supplements, which is not considered as “treatment” for malnutrition. As with the sepsis case, there are no recognized malnutrition criteria (World Health Organization, American Society for Parenteral and Enteral Nutrition, Global Leadership Initiative on Malnutrition) that specify what kind of nutritional supplement is required for treatment.

Clinicians should use the least invasive means to meet therapeutic goals. In the case of malnutrition, that means would be oral supplements if the patient is able to tolerate an oral diet. Requiring that total parenteral nutrition or invasive interventions such as feeding tubes be used when oral nourishment is an option simply subjects patients to potential harms including line infections and aspiration pneumonia.

These scenarios represent invented criteria that have no basis in the literature and arise either out of ignorance or from a deliberate intent to deceive. Personally, I hope it’s the former, for at least that error is remediable.

I recognize that payers may have some legitimate arguments in the denials process. But let’s stick to the truth and what makes clinical sense. We need to fight every instance of invented criteria or falsehoods, if for no other reason than to maintain our own integrity. Let’s keep the imaginary backstories to that odd couple at the bar.

Selected references:

• Kidney Disease Improving Global Outcomes Work Group. KDIGO Clinical Practice Guidelines for Acute Kidney Injury. Kidney International Supplements 2012:2 (1): 1-141.
• Phua J, Ngemg WJ, See KC, et al. Characteristics and Outcomes of Culture-Negative Versus Culture-Positive Severe Sepsis. Critical Care 2013; 17:8202.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.