Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate cancer.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is a patient who underwent an elective robotic prostatectomy and bilateral lymph node dissection, urethral suspension procedure for stress incontinence and pelvic floor biopsy. Past medical history was negative except for prostate cancer.  The estimated blood loss (EBL) during procedure was 100 cubic centimeters (cc).  The postoperative note indicated the patient was doing well in the post anesthesia care unit (PACU) and denied chest pain, and shortness of breath. Following surgery, the patient was transferred to the floor in stable condition. 

The patient was advanced to and tolerated a clear liquid diet and was managed conservatively throughout the hospitalization without any events or complications. Pain was well managed, and the patient was able to ambulate and had no nausea or vomiting. Urine was clear and the patient was stable to be discharged home with Foley (catheter) to leg bag and was instructed to continue clear liquid diet until passing gas and to contact their provider for follow up appointment. 

Based on the appeal and medical notes received, an inpatient hospital admission was not required for this procedure. The services performed describe an uncomplicated one-day ambulatory surgical procedure. The surgery was uneventful. There was no evidence of a complicated postoperative course requiring hospitalization, and the patient was discharged within 23 hours. Thus, the patient should have had the robotic prostatectomy performed under an observation status without acute inpatient admission. 

According to Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 27th Edition Prostatectomy, Radical ORG: S-960 (ISC), the goal length of stay is ambulatory or 1 day postoperative. 

Furthermore,  Milliman Care Guidelines (MCG) Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more of the following: Hemodynamic instability; Acute cardiac or peripheral ischemia; Cardiac arrhythmias of immediate concern;  Severe respiratory findings; Severe airflow or ventilation abnormalities, Anasarca; Neurologic abnormalities;  Altered mental status that is severe or persistent, Physiologic disorder (e.g., acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care,  Suspicion for or diagnosis of abdominal catastrophe, Temperature less than 95 degrees F (35 degrees C) (rectal),  Severe electrolyte abnormalities requiring inpatient care;  Severe anemia; High-risk low platelet count; Disseminated intravascular coagulation; adverse drug or systemic toxin reaction that is severe or persists despite observation; Severe pain requiring acute inpatient management; Inpatient monitoring  needed; Treatment requiring inpatient care; Emergency procedures needed.  Based upon these guidelines this patient should have been observed rather than placed in an acute admission, as the patient did not have any indication, as noted above for inpatient stay or prolonged stay. The patient did not need acute inpatient admission but rather observation status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.