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CurrentCurativePolicy CHP-IP-2026-245

Adrenalectomy for Pheochromocytoma and Abdominal Paraganglioma

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This policy governs medical necessity, inpatient level of care, continued-stay review, discharge readiness, documentation, and coding for laparoscopic, robotic, or open adrenalectomy for pheochromocytoma and resection of abdominal paraganglioma in adults and children.

Policy Summary

PayerCurative

PolicyAdrenalectomy for Pheochromocytoma and Abdominal Paraganglioma

Policy CodePolicy CHP-IP-2026-245

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument preoperative alpha blockade, including the agent, start date, and blood-pressure and heart-rate response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7-14 daysPreoperative alpha blockade

24-48 hoursImmediate postoperative monitoring

1-3 daysLaparoscopic stay

3-5 daysOpen resection stay

4Extended-stay triggers

Inpatient Coverage Criteria

Observation or outpatient instead of inpatient

There is no outpatient or observation pathway for pheochromocytoma resection.

Preoperative services: Preoperative alpha blockade and titration are outpatient unless severe hypertension or orthostatic symptoms require inpatient titration; biochemical testing and imaging are outpatient services.

A preoperative admission is appropriate only when outpatient blockade cannot be achieved safely.

Intensive care unit

ICU placement is appropriate when ANY of the following is present.

ICU level of care

Airway or ventilation: Invasive mechanical ventilation or a new or unstable artificial airway requiring continuous critical-care airway expertise.
Hemodynamic instability: Systolic blood pressure below 90 mm Hg or mean arterial pressure below 65 mm Hg persisting after initial fluid resuscitation, or any titrated vasopressor or inotrope infusion.SBP <90 mm Hg or MAP <65 mm Hg
Hemorrhage or coagulopathy: Ongoing hemorrhage needing repeated transfusion, massive transfusion protocol activation, or coagulopathy correction with frequent laboratory titration.
Acute respiratory failure: SpO2 below 90% despite FiO2 of 0.5 or more, escalating high-flow or noninvasive ventilation, or respiratory rate above 30/min with increased work of breathing.SpO2 <90%; FiO2 >=0.5; RR >30/min
Neurologic instability: Glasgow Coma Scale 8 or less, a fall of 2 or more points, a new focal neurologic deficit, or seizures needing intravenous antiseizure titration.GCS <=8 or decrease >=2 points
Frequent nursing intervention: Nursing assessment and intervention needed every hour or more often, exceeding step-down staffing.Every hour or more often
Post-resection hemodynamic crisis: Post-resection hypotension needing vasopressors or large-volume fluid resuscitation, or hypertensive crisis needing titrated intravenous infusion.
Cardiac instability: Sustained arrhythmia or catecholamine cardiomyopathy.

Step-down or intermediate care

Step-down or intermediate care is appropriate when the patient does not meet ICU criteria and ANY of the following is present.

Frequent assessment: Vital-sign or focused assessments every 2 hours, or hourly for a limited protocol-defined period, exceeding medical-surgical capability.Every 2 hours or hourly for a limited period
Continuous monitoring or respiratory support: Continuous cardiac telemetry or pulse oximetry for documented arrhythmia, ischemia, or respiratory risk, or stable noninvasive or high-flow respiratory support.
Monitored infusions: Non-titrated or slowly titrated infusions needing frequent monitoring.
Examples include insulin, heparin, or a weaning antihypertensive infusion.

Medical-surgical unit

A medical-surgical unit is appropriate when the patient does not meet ICU or step-down criteria and ANY of the following is present.

Medical-surgical level of care

Stable without vasoactive infusions: Hemodynamically stable off vasoactive infusions for at least 12 to 24 hours, with vital signs every 4 hours or less often clinically adequate.Off vasoactive infusions for 12 to 24 hours
Ongoing hospital-level services: Intravenous medications or fluids, parenteral analgesia, drain or wound care beyond home capability, or daily surgical reassessment remains necessary.
Stable recovery transition: Stable hemodynamics off infusions, glucose stable, diet advancing, and analgesia transition underway.

Discharge readiness

Discharge readiness requires ALL of the following.

Physiologic stability: Temperature below 38.0 C for at least 24 hours without antipyretic masking, heart rate below 100/min, systolic blood pressure at least 90 mm Hg or documented baseline, and SpO2 at least 92% on room air or baseline home oxygen.T <38.0 C; HR <100/min; SBP >=90 mm Hg or baseline; SpO2 >=92%
Pain controlled on an oral or other home-deliverable regimen.
Nutrition: Oral diet tolerated, or stable enteral or parenteral nutrition plan with supplies and caregiver teaching completed.
Laboratory stability: Hemoglobin stable without transfusion for 24 hours and electrolytes and renal function acceptable or covered by an outpatient monitoring plan.

Continued acute inpatient stay

Continued acute inpatient care is medically necessary when ANY of the following is documented; review occurs every 24 hours in ICU or step-down and every 24 to 48 hours on a medical-surgical unit.

Continued-stay criteria

Persistent hemodynamic instability: Hypotension or hypertension needing infusion or frequent titration beyond 48 hours.>48 hours
Recurrent hypoglycemia needing intravenous dextrose.
Adrenal insufficiency or complication: Adrenal insufficiency being stabilized, or surgical complication such as bleeding or pancreatic or splenic injury.
Unmet discharge readiness: Discharge-readiness criteria are not met because of a documented, actively treated clinical problem.

This policy applies to inpatient laparoscopic, robotic, or open adrenalectomy, including cortical-sparing adrenalectomy, for pheochromocytoma, and to abdominal paraganglioma resection when coded with the applicable procedures. Adrenalectomy for other adrenal tumors is outside this policy and is reviewed under the general surgical policy.

There is no outpatient or observation pathway for pheochromocytoma resection. Preoperative alpha-adrenergic blockade, titration, biochemical testing, and imaging are generally performed as outpatient services; a preoperative admission is appropriate only when blockade cannot be achieved safely as an outpatient, such as with severe hypertension or orthostatic symptoms.

Elective pheochromocytoma resection without documented preoperative alpha-adrenergic blockade, and without an urgent indication, is not medically necessary as scheduled. The request is referred for physician review because inadequate preparation increases the risk of intraoperative hemodynamic instability.

A continued acute inpatient stay after all discharge-readiness criteria have been met is not medically necessary at the acute level. Such days are considered custodial or provided for convenience rather than for an active acute clinical need.

A continued stay solely while awaiting post-acute placement, transportation, or caregiver availability does not meet acute criteria when there is no active acute need. The case is routed to physician review and discharge planning.

A stay beyond the expected length-of-stay benchmark does not meet continued-stay criteria as documented unless a specific extended-stay trigger is identified and supported by clinical information. Missing information should be requested before physician review.

Coding and Operational Thresholds

ICD-10-CM diagnosesICD-10

E27.5	Adrenomedullary hyperfunction
D35.00	Benign neoplasm of unspecified adrenal gland
D35.01	Benign neoplasm of right adrenal gland
D35.02	Benign neoplasm of left adrenal gland
C74.10	Malignant neoplasm of unspecified adrenal medulla
C74.11	Malignant neoplasm of right adrenal medulla
C74.12	Malignant neoplasm of left adrenal medulla

ICD-10-PCS proceduresICD-10

0GT20ZZ	Resection of left adrenal gland, open approach
0GT24ZZ	Resection of left adrenal gland, percutaneous endoscopic approach
0GT30ZZ	Resection of right adrenal gland, open approach
0GT34ZZ	Resection of right adrenal gland, percutaneous endoscopic approach
0GT40ZZ	Resection of bilateral adrenal glands, open approach
0GT44ZZ	Resection of bilateral adrenal glands, percutaneous endoscopic approach

CPT adrenalectomy proceduresCPT

60540	Adrenalectomy, open
60545	Adrenalectomy, open with adjacent retroperitoneal tumor
60650	Adrenalectomy, laparoscopic

MS-DRG FY2027 v44mixed

614	Adrenal and pituitary procedures with CC/MCC
615	Adrenal and pituitary procedures without CC/MCC

Revenue codesRevenue

0110	Room and board
0111	Room and board
0112	Room and board
0113	Room and board
0114	Room and board
0115	Room and board
0116	Room and board
0117	Room and board
0118	Room and board
0119	Room and board

1–10 of 35

1/4

Large tumor

Large tumor thresholdOver about 6 cm

Surgical approachOpen adrenalectomy

Other qualifying proceduresBilateral or cortical-sparing resection

ICU hypotension threshold

Systolic blood pressureBelow 90 mm Hg

Mean arterial pressureBelow 65 mm Hg

Documentation and Review Requirements

Documentation Required

Operative Indication and Decision

Document the operative indication, including the diagnosis, staging or relevant imaging, and the surgical or multidisciplinary decision supporting the procedure.

Diagnosis and operative indication
Staging or imaging findings
Surgical or multidisciplinary decision

Documentation Required

Preoperative Risk Assessment

Record the preoperative risk assessment, including the ASA physical status classification and relevant comorbidities that may affect perioperative management.

ASA physical status class
Relevant comorbidities
Perioperative risk considerations

Clinical Background

Pheochromocytomas secrete catecholamines, which can cause severe intraoperative hypertension and arrhythmia. After tumor resection, patients may instead develop hypotension and hypoglycemia, making postoperative monitoring of blood pressure, heart rate, and glucose clinically important.

Key Definitions

Alpha-adrenergic blockade

DefinitionPreoperative treatment with a selective or nonselective alpha blocker

Beta-blocker sequencingAdd beta blockade only after alpha blockade when needed for tachycardia

Treatment purposeControl catecholamine-related tachycardia after alpha blockade

Policy Summary

PayerCurative

PolicyAdrenalectomy for Pheochromocytoma and Abdominal Paraganglioma

Policy CodePolicy CHP-IP-2026-245

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument preoperative alpha blockade, including the agent, start date, and blood-pressure and heart-rate response.

SourceLink

On This Page

Post-ICU monitoring:

First 24 hours after transfer out of ICU when closer monitoring than a medical-surgical unit provides remains necessary.

Early post-resection monitoring: Blood pressure and heart rate every 1 to 2 hours with glucose checks every 1 to 4 hours during the first 24 hours after resection.BP/HR every 1-2 hours; glucose every 1-4 hours

No transfusion for 24 hours

Wound and drains: Wound stable; drains removed or output acceptable with documented home drain teaching.

Mobility and post-acute needs: Mobility at expected post-procedure level, or an appropriate post-acute level of care arranged for documented functional needs.

Safe transition plan: Medications reconciled; VTE prophylaxis plan established by risk; surgeon follow-up within 7 to 14 days; wound-care and return-precaution education completed; and home health or durable medical equipment arranged when needed.Follow-up within 7 to 14 days

Blood pressure and adrenal medication plan: Blood pressure and heart rate stable without orthostatic symptoms, and alpha blocker stopped or adjusted.

Glucose stability: Glucose stable without hypoglycemia for at least 24 hours.24 hours

Adrenal insufficiency management: Adrenal insufficiency excluded or treated after bilateral or cortical-sparing resection, with steroid education.

Follow-up testing and genetics: Follow-up plasma or urine metanephrines and genetic counseling planned.Metanephrines about 2 to 6 weeks after surgery

Necessary upcoming intervention: A medically necessary procedure or intervention is scheduled within the next 24 hours and cannot safely be performed outpatient.Within 24 hours

Threshold persists after initial fluid resuscitation; a titrated vasopressor or inotrope infusion also supports ICU placement

Acute respiratory failure oxygen threshold

Oxygen saturationSpO2 below 90%

Inspired oxygen thresholdDespite FiO2 of 0.5 or more

Additional respiratory criteriaEscalating high-flow or noninvasive ventilation, or respiratory rate above 30/min with increased work of breathing

Neurologic ICU threshold

Glasgow Coma Scale8 or less

Neurologic declineFall of 2 or more points

Other neurologic instabilityNew focal neurologic deficit or seizures requiring intravenous antiseizure titration

Early postoperative monitoring

Blood pressure and heart rateMonitor every 1 to 2 hours

GlucoseCheck every 1 to 4 hours

Monitoring periodDuring the first 24 hours after resection

Discharge physiologic stability

TemperatureBelow 38.0 C for at least 24 hours without antipyretic masking

Heart rateBelow 100/min

Blood pressureSystolic blood pressure at least 90 mm Hg or at documented baseline

Oxygen saturationSpO2 at least 92% on room air or baseline home oxygen

Postoperative glucose stability

Glucose statusStable without hypoglycemia

Required durationAt least 24 hours

Discharge requirementGlucose stability is required before discharge

Post-resection hypoglycemia red flag

Red-flag thresholdGlucose below 70 mg/dL after resection

Required responseTreat hypoglycemia

Monitoring responseIncrease glucose monitoring frequency

Documentation Required

Procedure and Planned Level of Care

Document the planned procedure or procedures, applicable CPT and ICD-10-PCS codes, the planned postoperative level of care, and the clinical reason for that level of care.

Planned procedure(s)
CPT and ICD-10-PCS codes
Planned postoperative level of care and rationale

Documentation Required

Daily Acute-Care Documentation

Provide daily progress notes that identify the active acute problem, the hospital-level service delivered, and the treatment plan for continued acute care.

Active acute problem
Hospital-level service delivered
Current treatment plan

Documentation Required

Clinical Monitoring Records

Maintain clinical monitoring records supporting the requested level of care, including vital signs, intake and output, relevant laboratory results, and procedure-specific monitoring.

Vital signs
Intake and output
Relevant laboratory results
Procedure-specific monitoring records

Documentation Required

Extended-Stay Evidence

For any stay beyond the expected length of stay, document the specific extended-stay trigger and the supporting clinical evidence.

Specific extended-stay trigger
Supporting evidence
Link between the trigger and continued acute care

Documentation Required

Discharge and Transition Plan

Document the discharge readiness assessment and transition plan, including follow-up, patient education, and required post-acute services.

Discharge readiness criteria
Follow-up plan
Patient and caregiver education
Post-acute services

Documentation Required

Pheochromocytoma-Specific Records

For pheochromocytoma or paraganglioma cases, include disease-specific records supporting diagnosis, preparation, and postoperative management.

Metanephrine results and imaging
Alpha-blockade agent, start date, and blood pressure and heart rate response
Postoperative blood pressure, heart rate, and glucose records

Billing Rule

Documentation Must Support Requested Amount

Support the full requested quantity, units, or duration with documentation. If only part of the request is supported, the unsupported increment may be reviewed separately.

Document the requested quantity, units, or duration
Support each requested increment with clinical documentation
The supported portion may be approved while only the unsupported increment is reviewed

Denial Risk

Missing Preoperative Alpha Blockade

Elective resection without documented preoperative alpha-adrenergic blockade, absent an urgent indication, does not meet medical-necessity criteria and is referred for physician review.

Document the alpha-adrenergic blockade before elective resection
Include the agent, start date, and response when applicable
Urgent indications must be documented if blockade is absent

Denial Risk

Stay After Discharge Readiness

Continued acute inpatient care after all discharge readiness criteria are met does not meet acute-level medical-necessity criteria. A documented, actively treated clinical problem must support any additional stay.

Document the remaining unmet discharge-readiness criterion
Identify the actively treated clinical problem supporting continued care
Days after readiness may be considered custodial or for convenience

Denial Risk

Nonclinical Discharge Delay

A stay solely awaiting post-acute placement, transportation, or caregiver availability does not support continued acute care when there is no active acute need.

Document any active acute need separately from the logistical delay
Route the case to physician review and discharge planning
This circumstance is not a basis for retroactive denial of days already authorized

Denial Risk

Unsupported Extended Stay

A stay beyond the expected length of stay requires documentation of a specific extended-stay trigger and supporting clinical evidence. The expected length of stay is a planning benchmark, not an automatic limit on covered days.

Identify the applicable continued-stay criterion
Document the trigger and supporting evidence
Request missing clinical information and refer for physician review when the record is insufficient

Documentation Required

Continued-Stay Support

Continued acute inpatient care is medically necessary when at least one qualifying condition is documented and actively supports the acute level of care. Continued-stay review occurs every 24 hours in intensive or step-down care and every 24 to 48 hours on a medical-surgical unit.

Hemodynamic instability requiring infusion or frequent titration beyond 48 hours
Recurrent hypoglycemia requiring intravenous dextrose
Adrenal insufficiency being stabilized or a surgical complication such as bleeding or pancreatic or splenic injury
Discharge readiness criteria are not met because of a documented, actively treated clinical problem
A medically necessary procedure or intervention is scheduled within 24 hours and cannot safely be performed outpatient

Billing Rule

Adverse Determination Requires Physician Review

An adverse determination may be issued only after physician review by a licensed physician of the same or similar specialty, with an opportunity for the requesting provider to participate in a peer-to-peer discussion.

Automated systems and non-physician reviewers may approve in full or in part but may not issue an adverse determination
Reviewing physician must meet applicable licensure, specialty, and medical-director requirements
Requests that do not meet criteria are referred for physician review

Billing Rule

Unsupported Increment May Be Adverse

When the service meets criteria but the requested quantity, units, or duration exceed what the documentation supports, approve the supported portion and subject only the unsupported increment to review.

Separate the supported amount from the unsupported increment
Do not treat the entire request as unsupported when only part exceeds the documentation
Concurrent review applies to each continued-stay period; days already authorized are not retroactively denied