Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems.
Treatment:  Inpatient Hospital.

The insurer denied the Inpatient stay.  The denial is upheld in whole.

The patient is a male who presented to the hospital with two distinct complaints, chest pain and urinary retention.  

Point-of-care ultrasound was performed in the emergency department (ED), which showed a dilated bladder with mild hydronephrosis bilaterally.  The prostate was quite large.  A Foley catheter was inserted for bladder decompression.  One liter (L) of urine was drained from the bladder, and as a result, the chest pain resolved, as well.  The patient was primarily admitted to the hospital for evaluation of chest pain.  Serial cardiac enzymes were ordered, as well as echocardiogram, and cardiology consultation.

The serial cardiac enzymes remained negative.  He was monitored on telemetry, which showed no abnormalities.  The chest pain was deemed to be noncardiac, and the patient was continued on aspirin, atorvastatin, and metoprolol.  The patient also reported that he exercises daily at the local gym, and can run several miles, without symptoms.  Therefore, no further cardiac workup was pursued.  The patient had a normal stress test two months prior.  

The patient was seen by urology, who diagnosed the patient with urinary retention.  The patient was started on Flomax, 0.4 milligrams (mg) nightly.  He was started empirically on ceftriaxone.  A formal renal ultrasound was performed, which showed relatively normal kidney size and renal parenchyma.  The bladder was collapsed around the Foley catheter, but the prostate was quite large.  The renal function remained normal, with a creatinine of 0.8.  The urologist assessed the patient and agreed with a voiding trial 48 hours after starting Flomax.  They recommended obtaining a bladder scan for the postvoid residual.  They recommended reinserting the Foley, if the post void residual (PVR) was greater than 250 milliliter (mL), and follow-up with urology.  The urologist recommended a voiding trial the following day.  They discussed performing straight catheterizations four times a day over an indwelling Foley catheter, given the patient's lifestyle.  The patient was finally discharged with home care, and was instructed to perform self-catheterizations for retention relief.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not medically necessary for this patient.  From the standpoint of chest pain, the patient ruled out for an acute coronary syndrome with serial cardiac enzymes within the first 24 hours of hospitalization.  There was no evidence of ischemic disease on EKG or telemetry.  The patient had a negative stress test only two months prior to this episode.  As a result, the chest pain evaluation could have been carried out without an inpatient stay, at a lower level of care status.

From the standpoint of urinary retention, the patient had mild hydronephrosis; it did not affect kidney function.  The renal function remained stable throughout the hospital stay.  The patient has benign prostatic hypertrophy, causing significant urinary retention.  It was appropriately relieved with the insertion of a Foley catheter, and initiation of Flomax.  Typically, this is managed with bladder decompression either with ongoing indwelling Foley catheter or intermittent catheterization.  Symptoms usually take a couple of weeks to resolve, after initiation of therapy.  There was no clear evidence of severe urinary tract infection, contributing to the symptoms, and there was certainly no evidence of sepsis.  As a result, this condition could also be managed without an inpatient stay.  As stated before, the urinary retention and hydronephrosis were relieved with bladder decompression, which does not require inpatient hospitalization and can be managed under a lower level of care status.