Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Left hydroureteronephrosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case is a male adult who presented to the hospital with a history of nephrolithiasis.  The patient complained of worsening left flank pain that radiated to the left side of the abdomen with associated nausea.  The patient had presented to the emergency department the prior night and had been discharged on pain medications.  Vital signs noted blood pressure of 153/83, heart rate of 82, respirations of 18, temperature of 98.3 degrees F, and oxygen saturation of 99% on room air.  Imaging noted mild left hydroureteronephrosis to the level of 3 millimeter (mm) obstructing calculus in the distal left ureter.  Laboratory testing noted elevated creatinine at 1.68.  The patient's white blood cell (WBC) count was increased at 11.96.  Urinalysis on the patient via microscopic examination noted elevated red blood cells with negative bacteria and small ketones.  Leukocyte esterase was negative.  An ultrasound of the kidney and bladder noted unchanged mild left hydronephrosis and non-visualization of the left urinary jet suggestive of persistent ureteral obstruction.  The patient was admitted to the clinical decision unit for trended creatinine and evaluation by urology.  The patient continued with intravenous fluids, pain medications, and antiemetics and reported that their pain had improved.  They were tolerating oral intake.  The patient was able to urinate, had no hematuria, and had no events overnight.  Creatinine had increased to 1.76 and white blood cell count had decreased to 7.  There were no signs of urinary tract infection.  A Urology consult was recommended given up-trending Creatinine.  There was a decision to admit the patient related to nephrolithiasis with left distal ureteral stone and worsening acute kidney injury.  There was consideration for possible surgery.  The patient wanted to avoid surgery.  The patient passed a small fragment in the urine.  The patient was treated with intravenous (IV) fluid, Flomax, medication optimization, and supportive care.  The patient's Creatinine level improved to 1.22.  

Inpatient admission is recommended for patients with kidney stones when there is hemodynamic instability, stage II acute kidney injury which includes a rise in creatinine to 2 times its baseline value or a reduction of more than 50% with estimated glomerular filtration rate from baseline, or when there is urine output less than 0.5 milliliters per kilogram per hour (mL/kg/h) for 12 hours despite adequate volume status.  There should be significant clinical findings such as worsening clinical status with rising creatinine despite appropriate treatment.  
Inpatient treatment may also be appropriate to address severe pain requiring acute inpatient management when intravenous opioid treatment is needed beyond observation care or only a stone removal procedure is needed.

In this case, the patient presented to the hospital due to persistent pain after being diagnosed with nephrolithiasis the previous evening. The documentation does not support that there is hemodynamic instability.  While worsening creatinine was acknowledged, the documentation did not support stage II acute kidney injury with a rise in creatinine to 2 times the baseline value or a reduction of more than 50% with estimated glomerular filtration rate from baseline.  The documentation did not support urine output less than 0.5 mL/kg/h for 12 hours despite adequate volume status.  The documentation detailed that the patient's pain improved and did not require management beyond observation level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient hospital services is not substantiated.