Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stone. 
Treatment: Inpatient Admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld. 

The patient was sent by her Urologist to the emergency department (ED) for intravenous (IV) antibiotics and to plan for cystoscopy in the morning. There was a 5-millimeter left ureterovesical junction (UVJ) stone with hydronephrosis recently seen by her outpatient Urologist on an outpatient computed tomography (CT) but a computed tomography arterial portography (CTAP) performed in the ED showed no evidence of acute obstructive uropathy. The Urologist felt the patient must have passed the stone since the previous CT scan. The patient was discharged home in stable condition and pain-free. 
"The acute passage of a kidney stone is the 9th most common cause of emergency room visits. Approximately 7-8% of women and 11-16% of men will have stone disease by age 70. The acute syndrome complex called renal colic implies obstruction of the collecting system or ureter, and the most common cause of obstruction is a kidney stone. Kidney stone colic is relatively constant in contrast to intestinal or biliary colic, which waxes and wanes or comes in waves. The onset of pain heralds the entrance of a stone into the collecting system and the ensuing obstruction. The intensity and location of the pain may vary with stone size, stone location, degree of luminal obstruction, and the suddenness of the obstruction but flank pain is very common. Similarly, hypotension also raises the likelihood of infection as the pain associated with renal colic typically induces hypertension and tachycardia." (Favus et al., 2018). 

"Kidney stones are a common disorder, with an annual incidence of eight cases per 1,000 adults. During an episode of renal colic, the first priority is to rule out conditions requiring immediate referral to an emergency department, then to alleviate pain, preferably with a nonsteroidal anti-inflammatory drug. The diagnostic workup consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal, such as urinary infection or a stone larger than 10 mm (millimeter). Conservative management consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging within 14 days to monitor stone position and assess for hydronephrosis. Asymptomatic kidney stones should be followed with serial imaging, and should be removed in case of growth, symptoms, urinary obstruction, recurrent infections, or lack of access to health care. All patients with kidney stones should be screened for risk of stone recurrence with medical history, basic laboratory evaluation, and imaging. Lifestyle modifications such as increased fluid intake should be recommended for all patients, and thiazide diuretics, allopurinol, or citrates should be prescribed for patients with recurrent calcium stones. Patients at high risk of stone recurrence should be referred for additional metabolic assessment, which can serve as a basis for tailored preventive measures." (Fontenelle et al, 2019). 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.