Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney Stone
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an elderly obese female with history of colonic polyp, adrenal mass, asthma, elevated cholesterol, hypertension, migraine, prediabetes, former smoker with large left renal stone burden who underwent left retrograde ureteroscopy and stone basketing, left ureteral stent placement, and left percutaneous nephrolithotomy. Her oxygen (O2) saturations prior to surgery on room air were 95 percent. Postoperative oxygen saturations decreased to 94 percent and then 93 percent and down to low 90's. The patient was placed on 2 liters per minute oxygen with saturations 91-95 percent. Medicine consult was obtained, and the patient seen on day #3. She was noted to have oxygen saturations of 88-89 percent on room air while sleeping and when awakened increased to 91-92 percent. The patient denied shortness of breath or chest pain. She felt well and her son felt she was at baseline, so she was discharged to home for follow up with her primary care physician (PCP) and pulmonary. She was felt to be at her baseline and could be safely discharged to home. The patient's catheter was removed on post-operative day (POD) number #1, and she voided after removal. A computed tomography was obtained on post-operative day #1 showing resolution of the hydronephrosis and no significant stones. The patient's hemoglobin/hematocrit was 12.9/41.3 on Day #1, 12.2/38.6 on Day #2 and 12.2/39.1 on day #3. The patient's pain was well controlled. A chest x-ray on day #1 showed normal lungs, and large heart. Chest x-ray on day #3 demonstrated discoid atelectasis of the left lower lung base, and large heart. 
Inpatient admission was denied as not medically necessary as the patient did not meet criteria including complex surgery that required a longer recovery after surgery than usually expected, severe complication from the procedure, a disease or condition like an active infection, bleeding disorder, dangerous heart problem or unstable blood pressure.

The proposed treatment was medically necessary.

This patient was obese, had a history of hypertension, asthma, pre-diabetes, increased cholesterol and was a known former smoker. Her admission notes do not support a known history of obstructive sleep apnea and there was no pulmonary clearance information provided. Postoperatively, the patient had a decrease in oxygen saturation which prompted a chest x-ray and the institution of oxygen, and a medicine consult for further evaluation and management. Overnight stay surgery has been reported in percutaneous nephrolithotomy (PCNL) patients, but in one article only 66% achieved this. In a systematic review of percutaneous nephrolithotomy in normal and obese patients, the length of stay ranged from 1.6 to 6.5 days. This patient's change in pulmonary status postoperative led to institution of oxygen therapy and a consultation to medicine service with the patient being seen on day #3. These unexpected postoperative changes which started postoperatively prolonged the patient's stay and led to the need for more complex care.