Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Renal colic, nausea and vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female with past medical history of asthma who underwent extracorporeal lithotripsy for right renal calculus eight millimeters which was without complication. She was discharged to home but developed severe pain, nausea and vomiting. 

On presentation to the emergency department (ED), the patient was nonfebrile, hemodynamically stable and oxygenating well. Her lab values demonstrated normal serum creatinine of 0.63, a white blood cell count of 12.5 and a urinalysis showing blood, leukocyte esterase negative and nitrite negative. A computed tomography (CT) scan demonstrated a 1.7 centimeter right-sided branching staghorn calculus, six millimeter non-obstructing right renal calculus, a three millimeter non-obstructing left renal calculus and what appeared to be a four millimeter stone in the bladder - possibly a passed stone. 

Due to ongoing nausea, vomiting and pain, the patient was admitted - she received one dose of intravenous (IV) Dilaudid and required a second for eight out of ten (8/10) pain. She was taken to the operating room and underwent cystoscopy and stent placement on the right. Her white blood cell count decreased to 6.6. She was discharged to home that day, after the surgery.  

The emergency department's disposition states the patient remained uncomfortable despite emergency room treatment - based on specifics of case, it was anticipated successful treatment would require more than two nights hospitalization. The health plan denied acute inpatient admission as the patient did not fulfill the Milliman Care Guideline (MCG) criteria for admission and her care could have been performed at a lower level of care.

Yes, the proposed inpatient admission was medically necessary.

This patient was noted to have severe pain requiring multiple doses of intravenous Dilaudid. The emergency department physician noted that the patient was not comfortable despite emergency department management. In addition, it is noted that the patient had ongoing nausea and vomiting and thus would require intravenous hydration. Thus per the Milliman Care Guidelines (MCG), this patient does meet criteria for acute inpatient admission and thus the acute inpatient admission would be considered medically necessary.

This patient presented with severe renal colic, nausea and vomiting after extracorporeal shockwave lithotripsy. She was noted to be afebrile, with normal renal function, urinalysis without signs of infection and with an elevated white blood cell count. She had a computed tomography scan to rule out perinephric hematoma and to assess for hydronephrosis. The computed tomography (CT) scan demonstrated what was possibly a passed stone and stones in both kidneys and a large stone in right kidney. 

Given the patient's pain, nausea and vomiting that necessitated intravenous pain medication, antiemetics and intravenous fluids, the patient required monitoring. The patient's pain resolved with stent placement the next morning and she was discharged to home. The notes indicate that the patient's pain was controlled with intravenous Dilaudid.  

The Milliman Care Guideline (MCG) criteria for inpatient admission include one or more of the following "hemodynamic instability [not noted in the emergency department notes], (2) acute renal failure [serum creatinine was normal], (3) bilateral obstruction [computed tomography was without hydronephrosis on either side and normal creatinine], (4) obstruction of single kidney [not applicable - the patient has two kidneys], (5) transplanted kidney with obstruction [not applicable - there is no history of transplant], (5) severe pain that requires acute inpatient management (6) vomiting that is severe or persistent, (7) urinary tract infection [urine analysis was nitrite negative and leukocyte esterase negative, (8) need for intravenous hydration, (9) stone management needing inpatient admission.   

The emergency department admission note and emergency department notes support that the patient remained uncomfortable despite emergency department treatment and that the patient received more than one dose of Dilaudid intravenously for eight out of ten (8/10) pain. The patient was also noted to have ongoing nausea and vomiting.

Thus, as the patient was noted to have persistent nausea and vomiting and had pain that persisted despite emergency department treatment, the patient does meet the Milliman Care Guideline (MCG) criteria for acute inpatient admission.