Diagnosis: Benign Prostatic Hypertrophy (BPH)

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This male patient has a history of benign prostatic hypertrophy (BPH), lower urinary tract symptoms (LUTS), and nicotine abuse. The patient presented to the hospital for scheduled transurethral resection of the prostate (TURP) to alleviate his LUTS secondary to BPH. The patient had his scheduled procedure performed without complications. The patient was transferred to the post anesthesia care unit (PACU). Sequential compression devices (SCD) were applied for deep vein thrombosis (DVT) prophylaxis, intravenous (IV) fluids given and intake and output (I/O) monitored. The patient was in the hospital overnight and then discharged home with outpatient follow up arranged.

The insurer has denied coverage for the inpatient admission as not medically necessary. They noted the TURP procedure and lack of pre- and post-operative complications. The appeal on behalf of the hospital was read in detail. Per MCG (Milliman Care Guidelines) Health (24th) Urologic Surgery or Procedure General Recovery Guidelines (GRG), the patient is noted to have met the GRG discharge parameter within 24 hours post-procedure. Also, per MCG Health (24th) Prostatectomy - Transurethral Resection (TURP), the patient is noted to have met the optimal recovery course discharge parameter within 24 hours post-procedure, and fails to meet guidelines for external stay (post-operative bleeding, TURP syndrome, concerns for sepsis, etc.). Goal length of stay (LOS) for TURP is ambulatory or one day post-operative, usually an overnight (observation) stay to ensure a safe discharge, if needed.

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

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