Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left renal mass

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned

This is the case of a man with a history of left sided renal mass and obesity. As per the preop note the patient has a left renal mass and otherwise has an unremarkable history. Hct (hematocrit) was 41.7. He was taken to the operating room and underwent a lap robotic left attempted partial nephrectomy. The EBL (estimated blood loss) was 1000 ml (milliliters) as the tumor was quite large and had multiple vessels going into it. He received 2 units PRBC (packed red blood cells) because of massive blood loss. 

As noted by MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care 26th edition Nephrectomy by laparoscopy ORG: S-872 the operative Status Criteria is Inpatient. Furthermore MCG also noted that Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days may be needed for: Larger (e.g., greater than 3.5 cm) or more complex (e.g. nephrectomy score greater than 7.5) tumors and expect brief stay extension; Care for comorbidities such as patient with active comorbidities, such as infection, heart failure, or pulmonary disease, may require continued inpatient care and one can expect brief stay extension; Complications of procedure such as operative complications may include hemorrhage, puncture or laceration of blood vessel or internal organ, diaphragmatic and pleural injury, or urinary leak, Postoperative complications may include cardiac or respiratory events, venous thromboembolism, ileus, renal dysfunction, postoperative infection, electrolyte abnormalities, or late bleed due to inadvertent arteriovenous fistula or pseudoaneurysm formation and one can expect brief stay extension; Conversion to open procedure and one can expect brief stay extension; Patient with dialysis-dependent end-stage renal disease and one can expect brief stay extension; Frail patient as frail patients have a higher risk of complications and non-home discharge and one can expect brief to moderate stay extension. MCG also noted for length of stay that "Among a cohort of 263 consecutive patients (median age 59 years) who underwent laparoscopic (with or without robot assistance) partial nephrectomy due to renal mass over an 8-year period, 60% were discharged on the first postoperative day.) In the same analysis, during the last 4 years of the study (155 patients), 74% of patients were discharged on the first postoperative day. A series of 101 consecutive adult patients undergoing robot-assisted laparoscopic nephrectomy for renal tumor or a benign condition reported a mean length of stay of 1.1 days, with 94% of patients discharged on postoperative day 1. A series of 455 adult patients (mean age 62 years) undergoing robot-assisted laparoscopic partial nephrectomy for renal tumor using an enhanced recovery after surgery pathway reported a mean hospital stay of 1.1 days. Analysis of a database of 960 adult patients undergoing robot-assisted laparoscopic partial nephrectomy found a median length of stay of 1 day." And finally, MCG also noted Optimal recovery course was noted and includes procedure completed with no evidence of ileus or bowel obstruction with renal function as expected and with Hemodynamic, no evidence of ileus or bowel obstruction, no evidence of postoperative or surgical site infection, pain absent or managed, and discharge plans and education understood. Once the patient reached these goals, he was able to be discharged. Thus, the inpatient status was appropriate.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.