Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. The denial was upheld.

The patient is a female with a past medical history significant for lupus and left kidney tumor associated with perinephric hematoma secondary to left renal angiomyolipoma who presented to the emergency department due to acute onset of abdominal pain that was primarily located in the left upper quadrant. At the time of admission, the patient denied nausea, vomiting, changes in bowel movements, tingling, numbness, or headache. The urology service was consulted from the emergency department and the urologist recommended admission for pain management. The admitting physician indicated in the history and physical (H&P) note that the urologist also suggested that no surgical intervention was needed.
The patient's vital signs at the time of admission were a temperature of 98.2, blood pressure was 125/64, respiratory rate was 16 breaths per minute, pulse rate was 81 beats per minute (bpm), and oxygen saturation was 98% on room air. The patient was awake and alert, in no acute distress, and appeared non-toxic. She was in no respiratory distress. The cardiovascular exam was within normal limits. The abdomen was soft, nontender, without guarding or rebound. There was no costovertebral angle (CVA) tenderness.
Her laboratory evaluation revealed that her sodium was 140, potassium was 4.0, chloride was 105, bicarbonate was 29, blood urea nitrogen (BUN) was 15, creatinine was 0.89, and glucose was 84. Her liver function tests were normal. White blood cell count was 6.69, hemoglobin was 12.9, hematocrit was 37.4, and platelets were 223. The urinalysis was unremarkable. The chest x-ray was essentially normal. A computed tomography (CT) scan of the abdomen and pelvis revealed a 7.6-centimeter (cm) exophytic fat-containing mass in the lower pole of the left kidney with acute hemorrhage consistent with acute and chronic hemorrhage into the large angiomyolipoma. There was no evidence of bowel obstruction or other acute abnormality in the abdomen and pelvis.
The patient was admitted to the hospital with left renal hematoma, perinephric hematoma, and lupus. In the hospital, the patient was followed by a urology service. It was suggested that the hematoma described on the CT scan did not represent active bleeding. During the hospital stay treatment with a Fentanyl patch was introduced, as well as treatment with oral pain medications for breakthrough pain.
As a result of the treatment provided in the hospital, the pain significantly improved, and the patient was discharged in satisfactory clinical condition.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The inpatient stay was not medically necessary for this patient.
The patient presented to the hospital with left upper quadrant abdominal pain, which was related to perinephric hematoma secondary to a left renal angiomyolipoma. The evaluation performed in the hospital revealed that the patient had no active bleeding and did not require any surgical intervention or procedure. Furthermore, the patient remained afebrile, hemodynamically stable, and did not require transfusion of packed red blood cells. There was no evidence that the patient had any concomitant infection.
Even though the patient received parenteral pain medications, there was no evidence that the patient did not tolerate oral pain medications or required longer-term treatment with parenteral pain medications to achieve reasonable pain control. There was no mention that the patient had any concomitant medical conditions that were unstable and required admission at the acute inpatient level of care.
Neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
The patient could have been treated at a lower level of care status.