Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder/Other/Obstructive Uropathy with Hydronephrosis of Left Kidney
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

This case involves a man who presented to the hospital with abdominal and left flank pain. The patient's symptoms are described as pressure, which rapidly worsened. He had associated nausea and vomiting, and diminished appetite. Evaluation in the outpatient setting, with a computed tomography (CT) scan, revealed a 7 millimeter (mm) stone at the left ureteropelvic junction (UPJ) with hydronephrosis. Despite treatment with oral Dilaudid, the patient's symptoms persisted, and he presented to the emergency department for evaluation. The patient had a history of kidney stones, requiring admission to the hospital. He typically passes the stone spontaneously. He is supposed to be taking Urocit-K, but was non-compliant. On examination, he had no flank tenderness to percussion and no rashes, and the cardiopulmonary exam was unremarkable. The temperature was 98 Fahrenheit, with a heart rate of 90 beats per minute (bpm) and a blood pressure of 172/90 millimeters of mercury (mmHg).

The next day, the patient experienced residual abdominal and back pain. The exam was unremarkable. The urologist contemplated urologic intervention, and the patient was made nothing by mouth (NPO). Repeat creatinine was unchanged; however, the white blood cell count decreased to 12.4. Later in the afternoon, the urologist completed a cystoscopy with the insertion of a ureteral stent. The patient had some mild blood-tinged urine postoperatively, and Pyridium was added for urinary discomfort.
The patient was deemed stable for discharge. Postoperative ultrasound showed no hydronephrosis. He was prescribed antibiotics and Flomax and was instructed to follow up with urology for stent removal. He was also instructed to continue straining the urine.
The issue is the medical necessity for the inpatient hospital admission.

I fully uphold the health plan's determination of medical necessity.

No. Inpatient hospitalization was not warranted in this case. This is a routine treatment course of obstructing kidney stone evaluation in the hospital, with cystoscopy, stent insertion, and subsequent discharge to the outpatient setting. There were no complicating factors. The patient did not appear septic, did not have pyelonephritis and did not have severe renal failure. The hydronephrosis was unilateral. The patient achieved adequate pain control post procedure and was discharged home the following morning.
Obstructing kidney stones with renal colic are routinely evaluated and treated under observation level of care, in the hospital setting, with urologic evaluation, cystoscopy, with stent placement. There is nothing complicated about this patient's presentation or treatment course. Once the obstruction was relieved, with a ureteral stent, the patient's symptoms improved, and he was discharged home. He was prophylactically treated with antibiotics but did not show signs of severe infections, sepsis, or pyelonephritis. The urinalysis was negative for a urinary tract infection (UTI). Therefore, there is no clear indication for inpatient admission. The presumed mild increase in the creatinine, and this patient with an unknown baseline, did not reach clinical severity to warrant an inpatient level of care.