Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria. 
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld. 

This is a female patient with a past medical history of immunoglobulin-A (IgA) nephropathy, proteinuria, hypertension, asthma, and obesity. The patient had an outpatient left kidney biopsy done that was complicated by hematuria. The patient was admitted for monitoring with hemoglobin near baseline. The patient's vital signs and exam were unremarkable except for trace edema. The patient was treated supportively overnight with stable vital signs and hemoglobin levels. The patient was discharged the next day without intervention.

Based on the review of the medical record, the patient was hemodynamically stable after her kidney biopsy without any exam or lab findings to suggest a level of acuity or intensity to warrant an inpatient level of stay. The patient's management was strictly supportive, and all her care provided was at a level where observation status would have been sufficient to safely care for this patient.    
  
As per Hogan et al., "Bleeding is the most common, clinically relevant complication after a kidney biopsy...The study] consider[s] a major bleeding complication as one that results in an alteration of clinical practice, leading to significant pain, extended hospital stay, urinary obstruction, requirement for blood transfusion, intervention, surgery, or death."

As per Visconti et al., "Percutaneous renal biopsy is an irreplaceable tool in the clinical practice of nephrologists to determine diagnosis, prognosis and treatment of several kidney diseases. This procedure is considered safe if it is performed in well-trained centers. Main indications are acute glomerulonephritis and nephrotic syndrome. Since bleeding is the major primary complication, careful evaluation of risks and benefits must be considered. The risk of complications in patients with coagulopathy may be reduced by using laparoscopic or transjugular renal biopsy or alternative approaches in obese patients. Despite progress in medicine over the years, renal biopsy is still an irreplaceable tool for nephrologists." 

As per Palsson et al., "Biopsies were generally well tolerated. Baseline hemoglobin was the dominant risk factor for [red blood cell (RBC)] transfusions, but female sex and eGFR [estimated glomerular filtration rate] <30 ml/min [milliliters per minute] per 1.73 m2 [meters squared] were also associated with a larger decline in hemoglobin after the procedure."

Based on the patient's admitting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, the patient's level of acuity did not meet any guideline requirement for inpatient hospitalization. Overall, the patient's condition could have been managed safely on an observation basis. Nothing was done for the patient during her inpatient level of care that could not have been provided on an observation level of care. 

The inpatient hospital admission is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.