Diagnosis: Bladder tumor

Treatment: Outpatient hospital procedure/surgery and monitoring

The insurer denied the outpatient procedure/surgery. The denial was reversed.

This is a female with past medical history of elevated cholesterol, thyroid nodule, gastroesophageal reflux disease (GERD), osteopenia, hematuria, sleep apnea and recent discovery of a bladder tumor. She presented for scheduled cystoscopy/transurethral resection of bladder tumor (TURBT) procedure. Her preoperative vitals were stable. The procedure was performed under general anesthesia and there were no complications. She was monitored in the Post Anesthesia Care Unit (PACU) post-operatively, and remained stable. The patient was discharged home after three hours of monitoring.

Per MCG Health Bladder: Transurethral Destruction of Lesion, the goal length of stay (LOS) is ambulatory, but the guideline does not specify the location of the procedure.

The Operating Room note indicates numerous papillary lesions were resected on the bladder neck (with a resectoscope) and fulgurated and a reddish area within the bladder was biopsied / fulgurated. Given the nature of this surgery, most urologists would have performed this procedure in the Hospital Outpatient Department, not an Ambulatory Surgery Center (ASC), given the potential for post-operative bleeding requiring continuous bladder irrigation (CBI), monitoring for clearing of urine, etc. The Cystoscopy procedures involving minimal biopsy/resection or fulguration are appropriate for performance in an Ambulatory Surgery Center (ASC), but resection of multiple tumors with fulguration is more appropriately performed in the outpatient hospital department.

The carrier's denial of coverage for the hospital outpatient procedure/surgery for CPT code 88305 and all associated codes is reversed. The medical necessity is substantiated.