Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old male who has been diagnosed with prostatic enlargement, gross hematuria, and bladder outlet obstruction. On 5/23/19, the patient underwent cystoscopy and transurethral resection of the prostate (TURP). The patient required continuous bladder irrigation on postoperative day one. He was given a void trial on 5/25/19 and discharged home. The patient has requested reimbursement for an inpatient hospital stay from 5/24/19 through 5/25/19. The Health Plan denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether an inpatient hospital stay from 5/24/19 through 5/25/19 was medically necessary for the treatment of the patients medical condition. Hematuria is the most common complication of TURP procedures in the immediate postoperative period. Many factors contribute to the risk for hematuria, including the operative course and postoperative recovery period. A study by Zepnick and colleagues reported that 4.7 % of patients required re-operation mostly due to significant hematuria. Patients who are treated with continuous bladder irrigation and tension to control bleeding should remain hospitalized. In this case, the patients urine was noted to be clear on 5/24/19, post-operative day one.The patient is a 63-year-old male who has been diagnosed with prostatic enlargement, gross hematuria, and bladder outlet obstruction. On 5/23/19, the patient underwent cystoscopy and transurethral resection of the prostate (TURP). The patient required continuous bladder irrigation on postoperative day one. He was given a void trial on 5/25/19 and discharged home. The patient has requested reimbursement for an inpatient hospital stay from 5/24/19 through 5/25/19. The Health Plan denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether an inpatient hospital stay from 5/24/19 through 5/25/19 was medically necessary for the treatment of the patients medical condition. Hematuria is the most common complication of TURP procedures in the immediate postoperative period. Many factors contribute to the risk for hematuria, including the operative course and postoperative recovery period. A study by Zepnick and colleagues reported that 4.7 % of patients required re-operation mostly due to significant hematuria. Patients who are treated with continuous bladder irrigation and tension to control bleeding should remain hospitalized. In this case, the patients urine was noted to be clear on 5/24/19, post-operative day one. This was due to continuous bladder irrigation and indwelling urinary catheter tension. The patient needed to be observed for hematuria after the bladder tension and irrigation were discontinued. The medical evidence supports the services at issue in this clinical setting. Therefore, the inpatient hospital stay from 5/24/19 through 5/25/19 was medically necessary for the treatment of this patient. was due to continuous bladder irrigation and indwelling urinary catheter tension. The patient needed to be observed for hematuria after the bladder tension and irrigation were discontinued. The medical evidence supports the services at issue in this clinical setting. Therefore, the inpatient hospital stay from 5/24/19 through 5/25/19 was medically necessary for the treatment of this patient.Findings:  The physician reviewer found that