Stacey Critzer, RN

A 76-year-old patient was admitted due to a worsening sacral wound, heavily influenced by various social determinants of health. After careful evaluation by the therapy and wound care teams, it became clear that she would greatly benefit from a skilled rehabilitation facility for continued strengthening and wound care before returning home.

Initially, the insurance company denied the request for skilled rehab and rejected the peer-to-peer conversation, arguing that her needs could be managed at home. This decision took the entire care team by surprise, as it was clear that her condition made it unsafe for her to go home.

With the patient’s approval, Stacey submitted an Expedited Appeal to the insurance company, demonstrating remarkable dedication. She crafted a detailed letter outlining every reason the patient should be approved for skilled rehabilitation. The letter included timelines and specific dates illustrating the progression of her health issues, highlighted the patient’s ongoing efforts to improve, and expressed Stacey’s willingness to provide any additional information necessary. By Tuesday, I received notification that the denial was overturned.

Stacey's thorough letter and her unwavering commitment to advocating for this patient triumphed, paving the way for improved health through skilled rehabilitation. Personally, I can count on one hand the number of times I’ve seen a denial overturned; it is no small feat and demands a significant investment of time, something we all recognize as invaluable. Stacey’s exceptional efforts are truly deserving of recognition.