Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for nephrolithiasis who presented to the emergency department with complaints of right flank pain, which she described as severe, continuous, sharp, non-radiating without any modifying factors. The pain was associated with nausea, multiple episodes of vomiting, and dysuria. There were no complaints of fever, chills, hematuria, changes in the urine culture. The patient stated that she had similar symptoms in the past, and at that time they were associated with a urinary tract infection.
At the time of the initial evaluation, the patient was afebrile, heart rate was 69 beats per minute (bpm), respiratory rate 17, and oxygen saturation 100% on room air.
At the time of admission, the patient was awake, alert, and oriented times 3, she appeared comfortable and was in no distress. The patient had no costovertebral angle (CVA) tenderness on both sides. The rest of the exam was unremarkable.
Laboratory evaluation revealed that the sodium was 140, potassium 4.7, chloride 105, bicarbonate 25, blood urea nitrogen (BUN) 9, creatinine 0.9, and glucose 128. Liver function tests were normal. The white blood cell count was 13.2, hemoglobin 12.6, hematocrit 40.1, and platelets 297.
The urinalysis had a significant amount of red blood cells, white blood cells, but few bacteria. It was negative for nitrite and had a moderate amount of leukocyte esterase.
A computed tomography (CT) scan of the abdomen and pelvis revealed 1.2 centimeters (cm) x 1.5 cm calculus in the right renal pelvis. The patient had mild right hydronephrosis. There was proximal mild hydroureter and no significant distal hydroureter. Mild periureteral edema surrounding the proximal ureter was suggestive of a recently passed calculus. The radiologist suggested that the right renal pelvis calculus could be intermittently abstracting.
In the hospital, the patient received treatment with intravenous fluids and antibiotics. She was started on Flomax.
The patient was evaluated by a urologist who recommended the placement of a nephrostomy tube.
The patient did not want to proceed with the treatment offered in the hospital and signed out against medical advice. At the time of discharge, the patient received a prescription for oral Ciprofloxacin. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.
The inpatient stay was not medically necessary. According to the accepted standards of care, admission at the acute inpatient level of care is usually required in cases of renal colic when patients present with signs of hemodynamic instability, acute renal failure, bilateral obstruction, obstruction in a single functioning kidney, obstruction in a transplanted kidney, severe pain requiring acute inpatient management, persistent vomiting, urinary tract infection, or need for stone removal procedure, as well as some other conditions.
In this particular case, the patient was hemodynamically stable, had normal kidney function. There was no evidence of bilateral obstruction. She did not have a transplanted kidney. The vomiting that was reported initially resolved during the short hospital stay. Even though the patient had signs of possible urinary tract infection, this diagnosis was not confirmed.
This patient most likely had renal colic, which resolved very quickly. She was given a prescription for an oral antibiotic prior to the discharge.
The review of the medical records demonstrated that the patient's symptoms improved very quickly. There was no overwhelming evidence that the patient had a urinary tract infection including pyelonephritis, because she was afebrile and had no flank tenderness on the exam.
Taking into consideration all of this information, the severity of the patient's condition and the complexity of the services provided did not justify admission at the acute inpatient level of care.