Appeal type: Medical necessity
Decision: Overturned

Diagnosis: End Stage Renal Disease

Treatment: inpatient kidney surgery services

The insurer denied coverage for inpatient kidney surgery services

The denial is overturned
 

This is the case of a patient with a history of End Stage Renal Disease (ESRD) secondary to immunoglobulin A (IgA) nephropathy. He had his regular blood work a few years ago when he found out he had chronic kidney disease (CKD) stage IV (4) at the time. As per the transplant evaluation note the patient started hemodialysis (HD) over one year ago. He is currently listed at a transplant center and would like to transfer over to another transplant center. He has potential living donors. His medical history is also significant for hypertension (HTN). His weight was 69.4 kilograms (kg). The plan was for an echocardiogram, chest x-ray (CXR), pulmonary function test (PFT), abdominal sonogram, routine pre-transplant labs and testing. Lab testing included Hepatitis B, C, HIV (human immunodeficiency virus), Rubella, rubeola, syphilis, varicella zoster antibody, Epstein - Barr virus (EBV) panel, and cytomegalovirus (CMV) panel. He was counseled regarding transplantation. He was seen by transplant nephrology where he was found to be a reasonable candidate for kidney transplant.

Psychosocial evaluation was performed where he was found to be an acceptable candidate for transplantation. It was noted that he has no history of substance abuse or alcohol abuse.

Committee evaluation was done and attested to. It was noted that he met transplant eligibility with CKD with glomerular filtration rate (GFR) less than 20 and had a stable support system; accepted the need for transplantation; had adequate cardiac and pulmonary function and had no absolute contraindications for transplant. His PFT's were reviewed, and no concerns were found. His cardiac risk was low. Labs were included and reviewed including QuantiFERON negative and Human leukocyte antigen (HLA) testing sent. CXR showed no active disease.

A cardiac echocardiogram was unremarkable with an ejection fraction (EF) of 55%.

A treadmill test showed no electrocardiogram (EKG) changes of ischemia.

PFT's showed mild obstructive lung disease without improvement with bronchodilators.

A ESRD Medicare entitlement form was included and reviewed.

An ultrasound of the abdomen showed mild hepatomegaly with bilateral kidneys with echogenic cortices which could reflect medical renal disease. No hydronephrosis was seen.

Based upon the information provided, the patient does meet criteria for coverage for kidney surgery based on national guidelines. As per Milliman Care Guidelines (MCG) Health: Inpatient and Surgical care 26th Edition: Renal transplant ORG:S-105 (ISC). 

This patient had the entire appropriate lab testing as required. This patient was also actively listed at another center which meant he had to have the lab testing as required for listing. He was transferring to this center now for transplantation. In terms of the drug history, there was no need to do drug testing as the social worker did do a drug history and no drug history was noted. Therefore, there was no need to do this testing. I therefore do believe that the patient does meet criteria for renal transplantation. The fact is that he was listed at another center and was transferring can only imply that the testing was done even at the other center as it is required for listing. In fact, it was noted that all the labs tests that the insurer wanted were ordered and resulted.

The reviewer, therefore, disagrees with the insurer and feels the kidney surgery in the form of a transplant is medically indicated for this patient and he does meet listing criteria for the transplant program and was felt to be a suitable candidate for transplant. 

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