Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone

Treatment: Hospital admission

The insurer denied coverage for hospital admission

The denial is upheld 

This adult patient had left renal colic due to 4.8 millimeters (mm) left ureteral calculus seen on a Computed Tomography (CT). The patient had nausea and vomiting and was admitted. A urology consultant recommended outpatient trial of passage and follow-up in three weeks. The records show that the patient was tolerating diet, no vomiting and mild pain. The patient passed the stone the day prior to discharge. 

Considering the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The records show that the patient could have been managed in an observation status, rather than inpatient admission. 

The hospital admission is not considered medically necessary for this patient. The records do not indicate the patient had severe problems such as low blood pressure, high fever, bleeding, or poor kidney function as required by Milliman Care Guidelines (MCG) Renal Colic and Kidney Stones criteria. The urological consultant also recommended outpatient trial of stone passage. Further, the records show that the patient was tolerating a diet, had no vomiting, and mild pain. The patient passed the stone the day prior to discharge. Given the above, the hospital admission is not considered medically necessary.

Per Miller & Lingeman (2007), "Initial evaluation of the patient with urolithiasis should include a complete medical history and physical examination. Typical symptoms of acute renal colic are intermittent colicky flank pain that may radiate to the lower abdomen or groin, often associated with nausea and vomiting. Lower urinary tract symptoms such as dysuria, urgency, and frequency may occur once a stone enters the ureter. Comorbid diseases should be identified, particularly any systemic illnesses that might increase the risk of kidney stone formation or that might influence the clinical course of the disease. Other important features are a personal or family history of kidney stones with previous treatments and stone analysis, and any anatomical abnormalities or surgery of the urinary tract. A complete history of drugs use can help identify those that are known to increase the risk of kidney stones." 

Per Zumstein et al., (2018) "Six guidelines with recommendations for the surgical treatment of urolithiasis to support urologists in decision-making were available for inclusion in our analysis. While there is a high grade of consensus for most stone scenarios, we also detected some discrepancies between different guidelines. These are, however, controversial situations where adequate evidence to assist with decision-making has yet to be elicited by further research."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a hospital admission is not substantiated.