Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty urinating, hematuria.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male who underwent a green light laser prostatectomy and presented to Emergency Department with complaint of inability to void since with blood from the penis with attempts to void. In the Emergency Department, he was noted to be afebrile with stable vital signs. Examination was notable for abdominal tenderness without guarding and distention of the suprapubic region. A bedside ultrasound demonstrated 600-800 milliliters of urine and an irregular shaped mass in the bladder, a possible clot. Urology was consulted and placed a three-way catheter (18 French) and recommended admission for continuous bladder irrigation. A repeat ultrasound with the catheter in place demonstrated the right kidney with a one centimeter echogenic focus (questionable angiomyolipoma), a normal left kidney, a decompressed bladder around the catheter, layering echogenic debris, and a prostate measuring 125 cc (cubic centimeters) with protrusion into the bladder. 

On the second hospital day, the notes indicate that continuous bladder irrigation (CBI) was clamped and urine was clear. It was hand irrigated for small clots. The patient was afebrile with stable vital signs. On hospital day three, the patient was afebrile with stable vital signs. The catheter was removed and the patient was still passing clots and straining to void. There was plan for possible reinsertion of a Foley catheter. On hospital day four, the patient was noted to be afebrile with stable vital signs and to have passed a trial of voiding; urine was improving was to light pink. He was discharged to home on Keflex and Flomax. Labs revealed a hematocrit of 35.1 and coagulation studies as follows: prothrombin time (PT) 12.1, partial thromboplastin time (PTT) 28/5, and international normalized ratio (INR) 1.01. Creatinine was 0.9.

No, the proposed acute inpatient admission was not medically necessary.
This patient presented with urinary retention and hematuria one month after green light prostatectomy. He was noted to be hemodynamically stable with normal oxygenation, and no documentation of significant co-morbidities. The patient had an ultrasound demonstrating a distended bladder for which a catheter was placed and continuous bladder irrigation was started. The next day, the continuous bladder irrigation was discontinued and the patient was noted to have urine remaining clear. The Foley catheter was removed and the patient experienced passage of a clot and straining to void. At this time, consideration of catheter placement was noted, but not performed. The patient was observed for another day and discharged to home on hospital day four after having been noted to have passed a trial of voiding. The patient's hemoglobin/hematocrit were stable and coagulation studies were normal. The patient's condition and treatment rendered, including catheterization, lab studies, voiding trials and follow-up with a urologist, could have been managed at a lower level of care other than inpatient admission.This patient had urinary retention and clots one month post green light laser prostatectomy. He was not identified to have any significant medical comorbidities and his coagulation studies were normal, and vital signs and blood count were stable. Thus, the patient could have been managed at a lower level of care. Additional catheterization and follow-up with a urologist could have been done at a lower level of care.