Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury/Chronic Kidney Disease/ Ureteral Stone
Inpatient Hospital Stay
The health plan denied the inpatient hospital stay
The health plan's determination is upheld

The patient is a male with a history of coronary artery disease (CAD), hyperlipidemia, diabetes mellitus, gallstones versus kidney stones who presented with 3 days of right lower quadrant abdominal pain. The pain was constant and was associated with a decreased appetite and emesis x1. He denied frequency, diarrhea, hematuria, dysuria, chest pain, fevers, chills or shortness of breath. He was seen in urgent care where a urinalysis (UA) showed + blood but no nitrite or leukocyte esterase and he was referred to the emergency room. He was afebrile with a blood pressure of 176/77 millimeters of mercury (mmHg), a pulse of 97 beats per minute (bpm), a respiratory rate of 16/minute and a room air pulse oximetry of 96%. On exam he was well appearing without acute distress and had mild right lower quadrant tenderness to palpation. Labs showed a creatinine of 3.2, a white blood cell count (WBC) of 12.96, a hemoglobin of 11.5, a blood urea nitrogen (BUN) of 29, a glucose of 328, a sodium of 129, a carbon dioxide (CO2) of 15 and a potassium of 6.6 with gross hemolysis in the sample. A repeat set of labs showed a potassium of 4.6, a CO2 of 23 and a creatinine of 3.1. The urinalysis showed large blood, >1000 glucose, 30 protein, 3-6 WBCs and >50 RBCs. A computed tomography (CT) of the abdomen and pelvis showed a .1cm right mid ureteral stone with moderate right sided hydronephrosis. He was admitted for inpatient management. Nephrology was consulted and felt the increased creatinine was pre-renal in etiology of likely chronic kidney disease from underlying diabetic nephropathy and recommended outpatient follow up. Creatinine improved to 2.6. Urology was consulted and recommended conservative management with intravenous (IV) fluids, Flomax, and pain control. He was discharged home in stable condition with outpatient follow up.

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

The inpatient hospital admission was not medically necessary for this patient based on the documentation provided. The patient presented with an elevated creatinine in the setting of right lower quadrant abdominal pain and was found to have a 1mm obstruction right ureteral stone. The patient was hemodynamically stable. There was no documented 3-fold increase in serum creatinine from baseline or a serum creatinine greater than 4mg/dl. There were no documented severe cardiac arrhythmias. There were no severe metabolic or electrolyte abnormalities. The patient did have an initial potassium of 6.6 but this was likely a lab error due to a hemolyzed sample as a repeat potassium was 4.6 in addition to the lack of clinically significant electrocardiogram (EKG) changes. There was no evidence of uremic encephalopathy, uremic pericarditis, or uremic bleeding. There was no severe respiratory distress. The patient did not have bacteremia or a documented complicated urinary tract infection with obstruction. The patient did not require an inpatient surgical procedure to treat his ureteral stone nor did he require prolonged IVF fluids or pain management beyond what could be offered at an alternate level of care. There was no other documented clinical indication for an inpatient admission.