Diagnosis: Prostate cancer
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is upheld.

This is a male patient with a history of prostate cancer. The patient was seen in his urologist's office for a new patient evaluation. A bone scan was negative for any metastatic disease. The physician requests coverage for radical prostatectomy in an inpatient setting. The insurer has denied coverage for this as not medically necessary, stating that the records did not show why an inpatient hospital admission was required as there was no documentation of a severe underlying condition or medical comorbidity.

The appeal by the urologist is noted and read in detail. Per MCG (Milliman Care Guidelines) Health (26th) prostatectomy, radical the goal LOS (length of stay) is Ambulatory or 1 day postoperative. The usual course is that patients are kept in the hospital overnight for observation to ensure a safe discharge, and their LOS is usually less than 24 hours. This patient had no serious underlying medical condition or co-morbidity that would have required an inpatient hospital admission.

The surgery to remove the prostate in an inpatient hospital setting is not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for surgery to remove the prostate in an inpatient hospital setting is not substantiated.