Diagnosis: Left Achilles Rupture

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

Urinary retention is common after surgery and is a significant cause of potentially avoidable postoperative morbidity. Age, benign prostatic hyperplasia, and lower urinary tract symptoms are patient factors that can predispose to urinary retention. Operative time, administration of intravenous fluids, type of anesthesia, and type of procedure are other factors that may contribute to the development of urinary retention. [1] Neuraxial anesthesia causes transient detrusor dysfunction that can lead to mild incomplete bladder emptying or severe urinary retention with bladder overdistension. Urinary retention can increase morbidity and increase hospital length of stay. [2]

Per clinical documentation, the patient underwent repair of a left Achilles tendon rupture with neuraxial anesthesia. The patient developed postoperative urinary retention. Alpha-blockers were prescribed. The patient was noted to have a post-residual volume of 900 cc (cubic centimeters) and required intermittent catheterization. The patient began to start voiding spontaneously and was subsequently discharged home. Per MCG (Milliman Care Guidelines), Ambulatory Surgery Discharge and Complications, surgery performed on an ambulatory basis may require inpatient stay for postoperative effects not resolved or adequately managed. [3] The patient had a side effect of neuraxial anesthesia that was properly managed postoperatively, and the patient was discharged on when the urinary retention resolved. Per provided clinical documentation, peer-reviewed literature and MCG criteria, the requested inpatient admission was medically necessary.

The insurer's denial of coverage for a full hospital admission is overturned. Medical Necessity is medical necessity is substantiated.