Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right-sided flank pain and groin pain
 
Treatment: Inpatient hospital services

The insurer denied the Inpatient hospital services. The denial was reversed.

This patient is a female who presented to the emergency department complaining of right-sided flank pain as well as groin pain.  The patient does have a history of prior kidney stones as well has anemia, depression, bipolar disorder, asthma, chronic obstructive pulmonary disease.  The documentation indicated the patient resides in a shelter.  She complained of ongoing pain that was worsening. She also complained of a cough feeling like something was stuck in her throat.  The documentation detailed the patient's prior records did show an 8.5 mm stone on the right ureter.  

The plan was to admit the patient and treat her with intravenous (IV) fluids as well as Toradol and have her undergo additional laboratory and diagnostic studies.  The patient's urinalysis did reveal large blood.  It was recommended that the patient begin Rocephin and undergo surgical intervention to place a stent in the next 24 to 48 hours.  The documentation indicated after admission that the patient was placed on NPO (nothing by mouth) status.  The patient was given morphine for pain control.  The patient did appear to be in mild distress secondary to pain and she continued treatment.  The documentation also detailed that she underwent a gynecology consultation due to decreasing hemoglobin.  She did have 2 fibroids that were discovered on ultrasound and it was recommended the patient continue with Provera and have her undergo a transfusion if needed. The patient underwent ureteroscopy with lithotripsy and stent placement under general anesthesia. Subsequently patient was deemed stable and she was discharged.

According to referenced literature, an inpatient admission may be needed for a patient when there is evidence of kidney stones as well as severe pain, urinary tract infection, the need for IV hydration, and a stone removal procedure is needed.  Within the documentation it was noted this patient did present complaining of worsening flank pain.  The documentation did detail she had recently been seen and diagnosed with a kidney stone.  She was recommended to have a stent placed however did not do so.  Therefore, the inpatient admission was needed as she did have prior care with ongoing worsening symptoms.  The documentation did detail she required morphine for pain control and had evidence of large blood in her urine.  The patient needed IV hydration as well and a stone removal procedure.  The patient underwent surgical intervention and continued to have rose-colored blood drain into her Foley.  She also complained of nausea and vomiting postoperatively.  Therefore, the continued inpatient services were the most appropriate level of care that could have been provided to this patient.  The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.