Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is upheld. 

Per the records, the patient presented to the Emergency Department (ED) for complaints of left flank pain. The patient stated the pain started 3 days prior and was stabbing pain rating it ten out of ten (10/10) on pain scale. The patient denied any nausea/vomiting/diarrhea, fevers, or urinary symptoms. The patient stated a history of previous kidney stones. Blood pressure was noted as 133/77 to the right arm while sitting, pulse was 84, respirations were 18, temperature was noted as orally 98.1 degrees Fahrenheit, and oxygen saturation was 98% (percent). The patient denied any current medication, vitamins, or supplements. 

A cystoscopy was performed with left urethral stent was placed under general anesthesia.

The patient was admitted to observation level of care with plans for a cystoscopy and stent placement. This procedure can be done as an outpatient procedure; therefore, inpatient level of care was not necessary.      

Favus, et al (2018) stated, "Urologic consultation should be obtained for possible surgical intervention for a number of reasons including stones with a low likelihood of spontaneous passage (large stones, proximal location), infection, obstruction, renal insufficiency or worsening renal function, and comorbidities that increase the risk of adverse outcomes (for example pregnancy). Depending upon the circumstances a number of procedures are available including ureteroscopic stone lithotripsy and extracorporeal shock wave lithotripsy for stone removal and percutaneous nephrostomy tube and JJ-stent for urinary drainage."

Per Fontenelle, et al (2019), "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 (millimeters). 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."

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

The insurer's denial of coverage for an inpatient hospital admission is upheld. Medical necessity is not substantiated.