From The Appeals Desk Episodes

Acute hypoxic respiratory failure is diagnosed by one of these three criteria: PaO2 less than 60 mm Hg SpO2 less than 90% PaO2/FiO2 ratio < 300 That's it. Payers like to add all sorts of clinical criteria alongside this. This...

Increasingly, insurance companies and third-party auditors are denying sepsis claims and DRGs based on the “Sepsis-3” article published almost 10 years ago. Specifically, they contend that if there is no SOFA score of 2 or gr...

Metabolic encephalopathy is a state of global cerebral dysfunction caused by systemic metabolic or toxic disturbances. Its presence raises the severity of illness of those patients afflicted with it, and it is a frequent deni...

There are two competing definitions of sepsis, called "Sepsis-2" and "Sepsis-3." They are vastly different, and it is causing enormous confusion with respect to diagnosing and coding for sepsis. I assembled a panel of experts...

There is a growing battle between payers and providers, each using AI to get the most money. Are doctors and hospitals using these tools inappropriately? Articles: AI by Doctors: https://www.statnews.com/2025/08/20/ai-scribe-...

If an insurance payer denies a claim, and we write an appeal. The very least the payer must do is write a letter in response.

CMS unveiled the WISeR Model, a pilot of prior authorization for traditional Medicare beneficiaries. I have mixed feelings about it. NYT Article: https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.h...

Many payers state that a 2016 Coding Clinics article allows them to deny sepsis DRGs. This is not true, and Dr. Hassaballa goes into the article and what is specifically says about sepsis. And, he issues an unequivocal condem...

Insurance companies will use obscure “Coding Clinics” articles to deny various DRGs. I asked appeal expert Dr. Vivek Tirmal of Sound Advisory Services all about this.

As we conclude Sepsis Awareness Month, Dr. Hassaballa discusses how the definition of sepsis changes depending on which insurance company the patient uses.

In this latest episode in the series, "From the Appeals Desk," Dr. Hassaballa discusses acute respiratory failure and how to protect yourself and mitigate against denials of this diagnosis by insurance companies. This is a pu...

In this episode, Dr. Hassaballa discusses the most frustrating denial he deals with: the "30 Day Readmission" denial. It is purported to be similar to that by CMS, but this is totally false. Reference: https://www.cms.gov/med...

Starting in 2024, Medicare Advantage plans must follow the Two-Midnight Rule. So, it behooves all clinicians to know that this rule is and document appropriately against it. Reference: https://www.beckerspayer.com/policy-upda...

It would be a travesty and a shame to have your documentation belie the truly great clinician you are. So it's high to focus on the assessment and plan, so we can really show the world the wonderful work we're doing on a dail...

In this episode, Dr. Hassaballa discusses medical necessity denials: what they are and how to deal with them. Resources: Interqual: https://www.changehealthcare.com/clinical-decision-support/interqual MCG: https://www.mcg.com...

Insurance company denials are terribly frustrating. There are a number of causes, and in this series, we will explore the types of denials and what we can do to mitigate them. Resources: "From the Appeals Desk": https://healt...