ModifiedCurativePolicy CHP-IP-2026-047

A047. Rhabdomyolysis

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This policy governs medical necessity for acute inpatient admission, observation or outpatient management, ICU and intermediate-level placement, medical-surgical care, continued stay, and discharge readiness for Curative commercial PPO and EPO members with rhabdomyolysis. It applies to all ages and covers rhabdomyolysis caused by exertion, trauma, drugs or toxins, seizures, heat illness, infection, or metabolic causes.

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ModifiedCurativePolicy CHP-IP-2026-047

A047. Rhabdomyolysis

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Policy Summary

PayerCurative

PolicyA047. Rhabdomyolysis

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionFor acute inpatient admission, document at least one clinical severity finding and at least one hospital-level service.

SourceLink

POLICY UPDATE CHANGES

The policy corrects the CMS v44 MS-DRG grouping for M62.82 as a principal diagnosis to MS-DRG 557-558 rather than the previously listed 640-642.

The applicable-code section adds traumatic muscle ischemia and compartment syndrome codes, renal replacement therapy ICD-10-PCS codes, MS-DRG 557-558, and related revenue codes.

The policy corrects the CMS v44 grouper assignment for M62.82 as a principal diagnosis from MS-DRG 640-642 to MS-DRG 557-558.

CK >5x ULNClinical definition threshold for rhabdomyolysis

McMahon ≥6Increased risk threshold for renal replacement therapy or death

K ≥6.5ICU-level hyperkalemia threshold

12 hoursContinued-stay review when CK >10,000 U/L or AKI is present

MS-DRG 557-558Corrected grouping for M62.82 as principal diagnosis

Medical Necessity and Level-of-Care Criteria

Initial inpatient admission

Covered for acute inpatient admission when ALL of the following are met.

Inpatient admission

Clinical severity finding: At least one of the following must be documented: AKI by KDIGO criteria; McMahon score of 6 or higher; potassium 5.5 mmol/L or higher or hyperkalemia with ECG changes; CK above 5,000 U/L with a rising trend or above 15,000 U/L at any time; metabolic acidosis with bicarbonate below 18 mmol/L or symptomatic hypocalcemia; suspected compartment syndrome; a serious underlying cause requiring inpatient care; or inability to maintain oral hydration or urine output below 0.5 mL/kg/h despite initial fluids.At least 1
Hospital-level service: At least one of the following must be required: intravenous isotonic fluid titrated to urine output of about 200 to 300 mL/h, or about 3 mL/kg/h in children, with intake-output monitoring; potassium, calcium, phosphate, creatinine, and CK every 6 to 12 hours until CK is falling and kidney function is stable; continuous cardiac monitoring for hyperkalemia; compartment pressure measurement or surgical evaluation for fasciotomy; or renal replacement therapy for refractory hyperkalemia, acidosis, volume overload, or uremia.At least 1

Observation or outpatient management

Observation or outpatient management is appropriate when ANY of the following applies and no inpatient criterion is met.

Lower-acuity management

Observation for moderate CK elevation: CK is 1,000 to 5,000 U/L with normal creatinine, normal potassium, and a McMahon score below 6, with repeat CK planned in 12 to 24 hours.CK 1,000-5,000 U/L; repeat CK in 12-24 hours
Observation with intravenous fluids
Outpatient exertional rhabdomyolysis: The member is healthy, with normal creatinine and electrolytes, CK falling on repeat testing, and ability to maintain oral hydration.Repeat CK in 24-72 hours
Outpatient follow-up
Asymptomatic CK elevation:

Intensive care unit

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

ICU-level clinical criterion: Potassium is 6.5 mmol/L or higher, or hyperkalemia with arrhythmia or ECG changes is not resolving with initial treatment; oligo-anuric AKI requires urgent continuous renal replacement therapy; volume overload causes respiratory compromise; or heat stroke, neuroleptic malignant syndrome, or sepsis is accompanied by shock, altered consciousness, or disseminated intravascular coagulation.At least 1

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following is present and ICU criteria are not met.

Intermediate-care criterion: Potassium is 5.5 to below 6.5 mmol/L and requires continuous cardiac monitoring with repeat checks every 2 to 4 hours; high-volume fluid therapy is required in a member with heart failure or reduced ejection fraction and requires close volume assessment; or post-fasciotomy monitoring is required with ongoing high CK and AKI.At least 1; ICU criteria absent

Medical-surgical unit

A medical-surgical bed is appropriate when ANY of the following applies and higher-level criteria are not met.

Medical-surgical criterion: Intravenous fluid therapy is required with laboratory monitoring every 6 to 12 hours, normal potassium, and stable hemodynamics; or AKI is stage 1 or 2 with adequate urine output.At least 1; higher-level criteria absent

Discharge readiness

Discharge is appropriate when ALL of the following are met.

Discharge readiness: CK has peaked and is declining on at least two measurements 12 to 24 hours apart; creatinine is stable or improving and urine output is adequate without high-rate intravenous fluid; potassium is below 5.0 mmol/L and calcium and phosphate are normalizing; oral fluids are tolerated with a hydration plan; the cause has been addressed; and follow-up is arranged within 1 week with repeat CK and creatinine.All 6 elements required

Nephrology follow-up is required after AKI stage 2 or 3. Recurrent episodes warrant evaluation for metabolic myopathy.

Continued stay

Continued stay is medically necessary when ANY of the following is documented.

Continued-stay indication: CK is still rising or not yet clearly declining; AKI is not improving or renal replacement therapy is ongoing; potassium is 5.5 mmol/L or higher or a significant calcium or phosphate abnormality requires intravenous therapy; compartment syndrome is managed with fasciotomy and wound care requiring inpatient services; or the underlying cause, such as sepsis, neuroleptic malignant syndrome, heat stroke, or toxic ingestion, still requires inpatient treatment.At least 1

Review every 12 hours when CK is above 10,000 U/L or AKI is present; otherwise review every 24 hours.

Traumatic crush injury requiring surgical care and compartment syndrome requiring fasciotomy are reviewed under the applicable trauma or surgical policy rather than routed solely under this rhabdomyolysis policy.

Admission for asymptomatic CK elevation without AKI, electrolyte disturbance, or a high-risk cause is not supported when observation or outpatient monitoring is appropriate. Such requests are referred for physician review.

Continued IV fluids solely to reduce CK below an arbitrary numeric target do not support ongoing hospitalization when kidney function and electrolytes are normal and CK is declining. Oral hydration and outpatient CK monitoring may be appropriate.

Routine sodium bicarbonate or mannitol used as the sole reason for inpatient stay is not supported because these therapies have not been shown to improve outcomes over fluid therapy.

Days spent awaiting rehabilitation placement without an ongoing acute need are routed to physician review and discharge planning rather than supported as continued acute inpatient days. Days already authorized are not retroactively denied.

Applicable Codes and Clinical Thresholds

ICD-10-CM: RhabdomyolysisICD-10

M62.82

Rhabdomyolysis

ICD-10-CM: Traumatic muscle ischemia and nontraumatic compartment syndromeICD-10

T79.6XXA	Traumatic muscle ischemia
M79.A11	Nontraumatic compartment syndrome
M79.A12	Nontraumatic compartment syndrome
M79.A19	Nontraumatic compartment syndrome
M79.A21	Nontraumatic compartment syndrome
M79.A22	Nontraumatic compartment syndrome
M79.A29	Nontraumatic compartment syndrome
M79.A3	Nontraumatic compartment syndrome
M79.A9	Nontraumatic compartment syndrome

ICD-10-PCS: Renal replacement therapyICD-10

5A1D70Z	Renal replacement therapy
5A1D80Z	Renal replacement therapy
5A1D90Z	Renal replacement therapy

MS-DRG: Tendonitis, myositis and bursitisRevenue

557	Tendonitis, myositis and bursitis
558	Tendonitis, myositis and bursitis

MS-DRG: Renal failureRevenue

682	Renal failure
683	Renal failure
684	Renal failure

Revenue codesRevenue

0120	Revenue code
0200	Revenue code
0206	Revenue code
0250	Revenue code
0300	Revenue code
0730	Revenue code
0800	Revenue code

Diagnosis and MS-DRG grouping correctionmixed

M62.82	Rhabdomyolysis; as principal diagnosis, groups to MS-DRG 557-558 under the CMS v44 grouper
MS-DRG 557-558	Corrected CMS v44 grouper assignment for M62.82 as principal diagnosis
MS-DRG 640-642	Grouping previously listed for M62.82 but identified as incorrect
MS-DRG 642	Inborn and other disorders of metabolism

Rhabdomyolysis CK definition

Clinical thresholdCK above 5 times the upper limit of normal

Approximate CK levelRoughly above 1,000 U/L

MyoglobinuriaMay be present or absent

McMahon score

Risk thresholdMcMahon score of 6 or higher

Clinical significance

Authorization, Documentation, and Review Requirements

Prior Authorization

Initial Inpatient Admission

Acute inpatient admission is medically necessary only when the record documents at least one clinical severity finding and at least one required hospital-level service.

Severity finding: AKI by KDIGO criteria; McMahon score ≥ 6; potassium ≥ 5.5 mmol/L or hyperkalemia with ECG changes; CK > 5,000 U/L with a rising trend or > 15,000 U/L at any time; metabolic acidosis with bicarbonate < 18 mmol/L or symptomatic hypocalcemia; suspected compartment syndrome; a serious underlying cause requiring inpatient care; or inability to maintain oral hydration/urine output < 0.5 mL/kg/h despite initial fluids.
Hospital-level service: titrated IV isotonic fluid with intake-output monitoring; potassium, calcium, phosphate, creatinine, and CK every 6–12 hours until CK is falling and kidney function is stable; continuous cardiac monitoring for hyperkalemia; compartment-pressure measurement or surgical evaluation; or renal replacement therapy for refractory hyperkalemia, acidosis, volume overload, or uremia.

Prior Authorization

Continued-Stay Authorization

Continued-stay authorization requires documentation of an ongoing inpatient need and is reviewed every 12 hours when CK is above 10,000 U/L or AKI is present, and otherwise every 24 hours.

Clinical Context

Rhabdomyolysis is skeletal muscle breakdown that releases creatine kinase (CK), myoglobin, potassium, phosphate, and urate into the circulation. It is generally defined as muscle injury with CK above 5 times the upper limit of normal, with or without myoglobinuria. Important complications include acute kidney injury, hyperkalemia, hypocalcemia, metabolic acidosis, compartment syndrome, and disseminated intravascular coagulation. Early adequate isotonic IV fluid is the core treatment; CK alone is an imperfect predictor of kidney injury, and low-risk exertional cases with normal renal function and electrolytes may be managed with observation or oral hydration.

Key Clinical Definitions

Rhabdomyolysis

DefinitionClinical muscle injury

CK criterionCK above 5 times the upper limit of normal

MyoglobinuriaWith or without myoglobinuria

McMahon score

PurposeValidated risk score for renal replacement therapy or death

Component variablesAge, female sex, cause, initial creatinine, calcium, phosphate, bicarbonate, and CK above 40,000 U/L

Risk thresholdA score of 6 or higher indicates increased risk

Policy Summary

PayerCurative

PolicyA047. Rhabdomyolysis

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionFor acute inpatient admission, document at least one clinical severity finding and at least one hospital-level service.

SourceLink

On This Page

CK elevation is below 5 times the upper limit of normal and there is no AKI.

Indicates increased risk of renal replacement therapy or death

Score componentsAge, female sex, cause, initial creatinine, calcium, phosphate, bicarbonate, and CK above 40,000 U/L

Inpatient hyperkalemia

Potassium thresholdPotassium 5.5 mmol/L or higher

ECG criterionAny hyperkalemia with ECG changes

Inpatient severity findingEither criterion qualifies as a clinical severity finding for inpatient admission

Inpatient CK severity

Rising CK thresholdCK above 5,000 U/L with a rising trend

Marked elevation thresholdCK above 15,000 U/L at any time

Inpatient severity findingEither CK pattern qualifies as a clinical severity finding for inpatient admission

Metabolic acidosis

Bicarbonate thresholdBelow 18 mmol/L

Clinical conditionMetabolic acidosis

Inpatient severity findingMetabolic acidosis or symptomatic hypocalcemia qualifies as a clinical severity finding

Target urine output during IV fluids

Adult targetAbout 200–300 mL/h

Pediatric targetAbout 3 mL/kg/h in children

Treatment contextTitrated intravenous isotonic fluid with intake-output monitoring

ICU hyperkalemia

Potassium thresholdPotassium 6.5 mmol/L or higher

Arrhythmia criterionHyperkalemia with arrhythmia

Persistent ECG criterionHyperkalemia with ECG changes not resolving with initial treatment

Intermediate-care hyperkalemia

Potassium range5.5 to below 6.5 mmol/L

Cardiac monitoringContinuous cardiac monitoring required

Repeat checksRepeat checks every 2 to 4 hours

Medically necessary when CK remains elevated without a clear decline; AKI has not improved or renal replacement therapy continues; potassium is ≥ 5.5 mmol/L or a significant calcium/phosphate abnormality requires IV therapy; compartment syndrome requires inpatient fasciotomy or wound care; or the underlying cause still requires inpatient treatment.

Unsupported block type: documentation

Documentation Required

Required Clinical Documentation

Submit clinical documentation that establishes the cause and timing of the muscle injury, the severity and trajectory of illness, the treatment and monitoring provided, and the patient's response. The record should support why inpatient or continued-stay services remain necessary.

Document cause and timing: exertion, trauma, drugs, seizure, heat, or infection.
Include serial CK; creatinine with baseline; potassium, calcium, phosphate, bicarbonate; and urinalysis, including blood on dipstick without red cells.
Include the McMahon score calculation; urine output and fluid balance; ECG when potassium is elevated; compartment examination and pressure measurement when performed; medication review, including statins, antipsychotics, and stimulants; and the discharge plan.

Billing Rule

Support the Requested Scope

The submitted documentation must support the requested quantity, units, and duration of services. When criteria are met but the request exceeds the documented need, approve the supported portion and refer only the unsupported increment for physician review.

Document the clinical basis for the requested level of care, treatment volume, monitoring frequency, and continued-stay duration.
The absence of a criterion specifically addressing a service is not, by itself, a basis for an adverse determination; a physician must apply generally accepted standards of medical practice.

Denial Risk

Low-Risk Asymptomatic CK Elevation

Admission is not supported for asymptomatic CK elevation without AKI, electrolyte disturbance, or a high-risk cause when observation or outpatient monitoring is appropriate. Such requests are referred for physician review rather than denied by an automated system or non-physician reviewer.

Document the presence or absence of AKI, electrolyte abnormalities, high-risk causes, CK trend, and the rationale for observation or outpatient monitoring.

Denial Risk

Fluids Solely to Lower CK

Continued IV fluids solely to drive CK below an arbitrary numeric target are not supported when kidney function and electrolytes are normal and CK is declining. Oral hydration and outpatient CK monitoring are appropriate when there is no other acute inpatient need.

Document the fluid indication, urine output, kidney function, electrolyte status, CK trend, and any other condition requiring hospitalization.

Denial Risk

Bicarbonate or Mannitol Alone

Routine sodium bicarbonate or mannitol as the sole reason for an inpatient stay is not supported. Evidence has not shown improved outcomes over fluid therapy, so these adjuncts alone do not establish medical necessity for admission or continued hospitalization.

Document any separate acute indication for inpatient care and the clinical rationale for bicarbonate or mannitol when used.

Denial Risk

No Ongoing Acute Need

Days spent awaiting rehabilitation placement without an ongoing acute need are routed to physician review and discharge planning. They do not support continued acute inpatient care, and days already authorized are not retroactively denied.

Document any ongoing acute condition, inpatient treatment, monitoring, or service that prevents safe discharge.

Documentation Required

Criteria Not Met

When the request does not meet the stated criteria, refer it for physician review before any adverse determination. Automated systems and non-physician clinical reviewers may not issue an adverse determination.

The reviewing physician must be licensed in the same or similar specialty, meet applicable plan and state requirements, and offer the requesting provider a peer-to-peer discussion.

Billing Rule

Unsupported Quantity or Duration

If the documentation supports only part of the requested quantity, units, or duration, approve the supported portion and refer only the unsupported increment for separate physician review.

Do not issue an adverse determination for the entire request solely because an increment is unsupported.
Document the clinical basis for the approved portion and the specific quantity, units, or duration that requires further review.

AKI (KDIGO)

Creatinine change within 48 hoursRise of 0.3 mg/dL or more

Creatinine change within 7 daysRise to 1.5 times baseline or more

Urine-output criterionBelow 0.5 mL/kg/h for 6 hours