Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydroureter. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient is an adult who presented for elective urologic surgery. The patient underwent pre-assessment. The patient was seen by the primary care provider (PCP) for medical clearance. The patient had obtained cardiac clearance and was noted to be moderate risk for a low-risk procedure. The patient had no active cardiac issues. The PCP cleared the patient and felt the patient was medically optimized for surgery. 

The patient underwent an uneventful robotic assisted left ureteral reimplant and stent placement for left ureteral dysfunction. The ureteral defect was identified, was transected, and ureteral reimplant was done. The estimated blood loss (EBL) was minimal. The patient was discharged from the Post Anesthesia Care Unit (PACU) with stable vital signs, and fully awake. 

The patient did not require inpatient hospital admission but rather 23-hour observation following an uneventful laparoscopic robotic assisted ureteral reimplant and stent placement. Based upon Milliman Care Guidelines (MCG) Health General recovery Care 27th Edition Urologic surgery or procedure General Recovery Guideline (GRG): SG-US (ISC GRG) Operative Status Criteria is Ambulatory for Percutaneous, cystoscopic, or endoscopic procedures; Most biopsies; Male sterilization; elevated blood pressure pre-biopsy, or age older than 70 years); Procedure is usually performed on ambulatory basis, but inpatient stay is needed. There was no indication that this was an inpatient procedure but rather a procedure that could have been done under observation. 
	
In addition, MCG Health General Recovery Guidelines 27th Edition Ambulatory Surgery or Procedure GRG: PG-AS (ISC GRG) notes that potentially ambulatory surgery or procedure covered by this guideline (such as not covered more specifically by another guideline) may proceed on an ambulatory basis due to the absence of ambulatory surgery exception criteria, as indicated by all of the following: No inpatient care needed for clinically significant disease or condition identified preoperatively; Complex surgical approach or situation not anticipated (e.g., prolonged airway monitoring due to severe obstructive sleep apnea); No drug-related risk identified preoperatively; No inadequate outpatient care situation. In this case the patient could have been managed as an outpatient with a 23-hour observation without acute inpatient hospitalization as there was no indication that the patient met any exception criteria for inpatient status. 

Finally, 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 peripheral ischemia (such as pulseless, cool, mottled, or cyanotic extremity; 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 (such as acute acidosis, thyroid storm, adrenal crisis) that is severe or persists despite observation care, suspicion for or diagnosis of abdominal catastrophe (such as Peritoneal signs, Temperature less than 95 degrees Fahrenheit (35 degrees Celsius) (rectal); 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. 

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 inpatient hospital admission is not substantiated.