Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stones
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital Stay
The determination is: Upheld

The patient is a female with a past medical history significant for nephrolithiasis and renal colic who was 33 weeks pregnant and presented to the emergency department (ED) with sudden onset of right-sided low back pain and flank pain.
The patient described the pain as sharp, 8/10 in severity, with radiation to the right flank and groin. At the time the patient was seen by the admitting physician, her pain somewhat improved, and the patient rated the pain in the range between 2 and 5. The patient endorsed urinary urgency and increased frequency of urination. The patient denied contractions, leakage of fluid, or vaginal bleeding, and endorsed good fetal movement.
On the physical exam, the patient was afebrile. Her heart rate was 85 beats per minute (bpm), and her blood pressure was 90/50 millimeters of mercury (mmHg). There was mild tenderness to deep palpation over the right lower back and flank area. The patient was alert and oriented.
Laboratory evaluation including a urinalysis demonstrated only 2 white blood cells, 14 red blood cells, and some bacteria, but negative urine nitrite or leukocyte esterase. The white blood cell count was 11.6, with a hemoglobin of 13.3, a hematocrit of 38.1, and platelets of 182. An abdominal ultrasound revealed mild to moderate right hydronephrosis.
The patient was admitted to the hospital with renal colic on the right side. She received treatment with intravenous fluids, and oral hydration was encouraged. A urine culture was sent, and the patient was started on Macrobid. During the hospital stay the patient was noted to have a slightly elevated liver function test. However, they were down trended, compared to the previous laboratory checks.
As a result of the treatment provided in the hospital, all her symptoms resolved. The patient tolerated oral intake with no nausea or vomiting. She was discharged home. At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The hospital stay was not medically necessary for this patient at the acute inpatient level of care. 
The patient presented to the hospital with renal colic that was not associated with hemodynamic instability or acute kidney injury. Even though the patient's blood pressure was on the low side, this was typical for pregnancy. Most women experience low blood pressure during pregnancy. Low blood pressure occurs as a result of more blood being rerouted to the fetus. It also occurs as the blood vessels expand in this stage to accommodate more blood.
Furthermore, there was no evidence of bilateral obstruction as a result of nephrolithiasis.
Initially, the patient had severe pain; however, by the time the patient was seen by the admitting physician, the pain significantly improved and resolved on the same day. In addition, there were no complaints that the patient had severe nausea and vomiting and was unable to tolerate oral hydration. Furthermore, based on the urinalysis, the patient did not have a urinary tract infection. The patient did not need a stone removal procedure during the hospitalization.
Overall, she remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. 
This coincides with Milliman Care Guidelines (MCG) health inpatient and surgical care 26th edition criteria for renal colic and kidney stones. The patient did not meet those criteria to justify admission at the acute inpatient level.