Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary retention

Treatment: Continued inpatient hospital admission 

The insurer denied coverage for continued inpatient hospital admission.

The denial is upheld. 

This was a male patient with a history of pituitary macro-adenoma, status post endoscopic excision complicated by meningitis and intraoperative RICA injury with blindness and diabetes insipidus. He also had urinary retention. As per a work-up done at an outside facility, the patient's sodium fluctuations were thought to be related to impaired thirst mechanism and washed out gradient in kidney with a neurogenic component. The patient was seen by urology for urinary retention and it was suspected that the patient had a hypo-contractile bladder at baseline with increased sphincter tone, and that the patient's brain involvement, diabetes insipidus and bowel constipation may be contributing to inability to empty with risks of retained urine, bacteremia and renal damage. 

As per literature review, patients with urinary retention should undergo testing that includes a post-void residual (PVR) urine evaluation, which is a simple, noninvasive, and cost-effective volume measurement of urine within the bladder that can be performed with ultrasonography in the office. To date, there is no consensus on the cutoff volume to define acute urinary retention. Some studies posit that the bladder can be percussed when it contains 150 mL of urine and palpated with greater than 200 mL. No evidence supports a specific PVR threshold for patients with chronic urinary retention; however, the American Urological Association has recommended using a value greater than 300 mL that has persisted for at least six months and has been documented on two separate occasions. Patients with chronic urinary retention should be referred to a urologist if they are bothered by related symptoms or have evidence of renal or infectious complications resulting from retained urine. If PVR evaluation cannot be obtained or if the PVR is thought to be inaccurate, patients with suspected urinary retention should be catheterized for decompression of the bladder and accurate measurement of stored urine.
 
Based on the review of the medical record, the patient was neurologically stable and was undergoing bladder scans with catheterizations for residual urine after voiding. The patient's care could have been provided at a lower level of care. Neurosurgery noted that the patient was stable and there were no new neurological deficits. The patient had prior chronic urinary retention issues that were most likely related to his macroadenoma. The patient's urinary retention did not appear to be the result of postoperative urinary retention. Urology stated that if the patient's post-residual void remained elevated that a Foley catheter should be placed at his original consult; therefore, testing and Foley placement on the date at issue would have been appropriate. The patient's constipation issues could have been managed at a lower level of care and he was noted to have a bowel movement on the date at issue.

Based on the above, the medical necessity for the continued inpatient hospital admission is not substantiated. The insurer's denial should be upheld.