Appeal type: Medical necessity
Decision: Upheld

Diagnosis: 35 weeks pregnant; generalized weakness, malaise and severe right flank pain. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This patient is a female who was admitted for flank pain. The patient was at 35 weeks gestational age and presented to triage with complaints of generalized malaise and fatigue, lower extremity weakness and one episode of severe right flank pain. The patient was noted to have maternal and fetal tachycardia in the triage with the maternal heart rate (HR) up to the 120's and the fetal heart rate was up to the 180's. The patient was a noted to be afebrile on presentation. She had a prior history of nephrolithiasis and costovertebral angle (CVA) tenderness. 

She was admitted to inpatient care for antibiotics. The patient was noted to have no prior obstetrical history. She had a prior history of nephrolithiasis. There was no prior surgical history. She had no allergies and was on a prenatal vitamin daily. The examination noted her to be in no acute distress. The patient was not in respiratory distress. She had a nontender and non-distended abdomen. The vaginal examination noted the cervix to be long, closed and high. She had positive CVA tenderness and there was no lower extremity tenderness. She had a fetal ultrasound that noted a singleton, vertex presentation with an estimated fetal weight of 2410 grams. She had a normal amniotic fluid index (AFI) by a deepest maximal vertical pocket (DVP) of 4.4 centimeters (cm). The patient was assessed to have presumed pyelonephritis and was started on 1 gram (g) of Rocephin intravenously (IV) every (q) 24 hours. The patient was also scheduled in the outpatient setting for a urology follow up. She was to have vital signs per protocol with bedrest and intravenous fluids (IVF) with Lactated Ringers. She was on a regular diet. 

The patient was noted to be on bedrest and resting comfortably. She had no acute distress. She was feeling well and reported good fetal movements. She denied chills, rigors, vaginal bleeding, shortness of breath or dysuria. The exam was normal with mild CVA tenderness on the right. There was no guarding or rebound. The patient had a urine culture that was negative times 1 day. 
During the hospitalization, the patient was noted to have a normal complete blood count and a normal renal sonogram. The white count was 14.6. There were no renal calculi noted. Hydronephrosis was absent. 

An admission to an acute inpatient level of care is not supported or medically necessary as the services could be performed at an alternate level of care. Based upon a review of the clinical information, the patient presented with CVA tenderness and etiologies in pregnancy were evaluated for the pain to include ultrasound. She underwent monitoring that suggested absence of preterm labor given cervical exam. Her laboratory studies and the urinalysis were reassuring that there was no infection (urinary tract infection or pyelonephritis) but given suspect for infection, she was started on Rocephin.
There was a normal white count for pregnancy. There was an ultrasound with no renal stones in the kidney and no evidence of obstruction. On ultrasound there was no hydronephrosis. 

There were no signs of serious pathology requiring intervention. Conservative management was appropriate in this case with pain medication and monitoring with Rocephin (urine culture ultimately was negative). In this case, the patient would undergo these procedures in an office or outpatient setting for management given the lack of obstruction or acute infection. There were no signs of preterm labor to support admission. Thus, the condition of back pain with possible renal stone that is non-obstructing would be managed with pain medication, hydration and outpatient follow-up given this presentation.