Appeal type: Medical necessity
Decision: Upheld

Diagnosis: staghorn calculus status-post percutaneous nephrolithotomy
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
According to the patient's medical record, this is an adult who presented for elective urologic surgery.  Per the history and physical the patient has an 8 x 4 centimeter (cm) staghorn calculus in the left renal pelvis who presents for definitive left sided stone management through percutaneous nephrolithotomy (PCNL). Pre-operative clearance was obtained prior to surgery. Cardiac ultrasound was obtained pre-operative as well as stress test and both were normal.  

As per the brief operative note at, the patient underwent PCNL with fluoroscopy guidance and ureteral stent was placed. In the Post Anesthesia Care Unit (PACU) the patient had stable vital signs with good urine output. 

Progress notes by urology indicated he patient was stable with pain controlled and no nausea or vomiting. The urine was clear. The plans were clear liquids and continue foley.

Urology progress note the next morning indicated the patient was stable and was out of bed (OOB) with no acute events overnight with discharge planning. The patient was discharged to home later after having passed a trial of void after the foley was removed.

Past medical history (PMHX) included staghorn calculus, obstructive sleep apnea (OSA). In the operating room the patient underwent a left percutaneous nephrolithotomy (PCNL) and left ante grade ureteral stent placement. A foley catheter was placed. Estimated blood loss (EBL) was 100 milliliter (ml). This patient required admission for continued monitoring, and continued complex care of drains, intravenous (IV) hydration, and parenteral pain management. It was in the physician's judgment that admission to inpatient care was the safest alternative in this situation, considering the medical evidence available to the physician at the time an admission decision had to be made, and not based on retrospective clinical or laboratory data which became available only after admission. Admission was justified based upon Milliman Care Guidelines (MCG) 27th edition ambulatory surgery exception criteria GRG: CG-AEC (ISC GRG) for complex surgical approach or situation anticipated as indicated by a procedure that likely needs prolonged postop care or monitoring.

Based upon the records provided to me, the patient did not require inpatient hospital admission from but rather 23-hour observation following an uneventful percutaneous nephrolithotomy (PCNL) and ureteral stent placement. Procedure is usually performed on ambulatory basis, unless inpatient stay is needed. Thus, there was no indication that this was an inpatient procedure but rather a procedure that could have been done under observation. 

MCG Health Inpatient and surgical Care 27th Edition Nephrostomy, percutaneous ORG: S-890 (ISC) also notes that the procedure is indicated for 1 or more of the following: Stone removal in conditions not appropriate for less invasive procedures (e.g., ureteroscopy), as indicated by 1 or more of the following: Significant renal obstruction; Failure of extracorporeal shockwave lithotripsy (ESWL) or other less invasive procedures; Staghorn stone; Renal or upper ureter stone 20 mm or larger; Calyceal stone (e.g., inferior pole stone) or proximal ureteral stone 10 mm or larger; Significant urinary stone burden (e.g., hard stone such as calcium oxalate or cystine); Residual stones after open surgery; Stone in urinary diversion. The operative status criteria is ambulatory. Thus, this patient should have had the procedure done for the staghorn stone in an ambulatory setting as it was being done as an elective case.
	
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 services is not substantiated.