Inpatient Hospital Stay denials in California external review

What the reviewers wrote

Where the denial was 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 patient’s medical condition. Hematuria is the most common complication of TURP procedures in the immediate postoperative period.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital stay services. Findings: The physician reviewer found that the documented high risk of sudden death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter-defibrillators in this group of patients (Kutyifa, et al.; Klein, et al.). Current data from multiple trials support the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction less than or equal to 35%, along with guideline directed medical therapy. This patient’s ejection fraction was 25% per echocardiogram.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital stay. Findings: In this case, the patient was admitted with a diagnosis of unspecified injury of lower back. The records noted that he presented to an outside hospital with low back pain and lower extremity paresthesia and was transferred due to concerns for cauda equine. The patient reported onset of pain about one month prior while working out, and that the pain temporarily subsided with rest and recovery. The patient reported bilateral lower extremity paresthesias and radiculopathy over the past three days along with back pain. He reported that his bladder felt strange when he voided, but did not report any episodes of incontinence. Magnetic resonance imaging (MRI) did not show acute bony injury. There was no abnormal dumping or tethering of the cauda equina nerve roots.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for an inpatient hospital stay. The Health Plan denied the inpatient hospital stay as not medically necessary for the patient’s medical condition. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity of the requested inpatient hospital stay on the date in question. In this case, the patient was admitted in stable condition for a scheduled surgery. He improved clinically without any complications. By the date in question, the patient’s vital signs were stable, physical exam unremarkable, and his pain was noted as being well-controlled. He had a Foley catheter for voiding; was ambulating and could have been treated at a lower level of care.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Inpatient Hospital Stay, then check the rights and deadlines that apply to your plan.