Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis 
Treatment: Hospital Admission
The insurer denied the hospital admission.
The denial is upheld.

The patient is a female who initially presented to the emergency department with concerns of bright red blood per rectum and left lower quadrant abdominal pain. Pertinent history included hemorrhoidectomy, gastroesophageal reflux disease and migraine headache. Initial vital signs revealed a temperature of 36.8 Celsius (C), heart rate (HR) 90, blood pressure (BP) 123/64, respiratory rate (RR) 18, peripheral capillary oxygen saturation (SpO2) 98% on room air. 

The patient was admitted thereafter with an impression of acute blood loss anemia and nephrolithiasis with hydronephrosis. Treatment plan included a Protonix infusion, analgesia, anti-emetics, and consultations. Options were discussed and the patient was amenable to medical management. The patient was discharged thereafter. The subject under review is the medical necessity for the full hospital admission.

The full hospital admission was not medically necessary. Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. The patient could have been managed at a lower level of care status.

In regard to the kidney stone, Fontenelle et al. note pain relief is the priority in the acute management of renal colic. Immediate referral to a urologist or emergency department is warranted when medical analgesia is insufficient; when sepsis is suspected; when anuria, bilateral obstruction, urinary tract infection with renal obstruction, or obstruction of the sole functioning kidney are present; in women who are pregnant or have delayed menstruation (because of the risk of ectopic pregnancy); and in patients who have potential comorbidities or are older than 60 years, especially those with arteriopathy (because of the risk of leaking abdominal aortic aneurysm).[1]
The patient presented with left lower quadrant abdominal pain and was subsequently found to have a 3 centimeter (cm) calculus at the ureterovesicular junction. There was no evidence of a urinary tract infection. Treatment included intravenous fluids and anti-emetics. Urology consultation was obtained and recommended medical expulsion therapy. Following observation care, symptoms were controlled, and the patient was discharged.

In regard to the lower gastrointestinal bleed, Pasha et al. note acute lower gastrointestinal bleed (LGIB) is defined as bleeding of recent duration less than (<) 3 days that may result in hemodynamic instability, anemia, and/or the need for blood transfusion. The initial assessment is important in determining whether or not an urgent intervention is necessary in the patient with LGIB. Patients with clinical evidence of ongoing or severe bleeding, those with a transfusion requirement of greater than 2 units of packed red blood cells, and those with significant comorbidities may require admission and monitoring in an intensive care unit setting.[3]

The patient had a history of hemorrhoids and presented with one episode of bright red blood per rectum after repeatedly attempting to defecate. Initial evaluation documented the patient as afebrile and hemodynamically stable with a Hgb 13.3. Following intravenous fluids, Hgb returned at 10.6 with a recheck of 12.2 grams per deciliter (g/dL). No bleeding was observed during the hospital stay. Gastroenterology consultation was obtained who felt the bleed was due to hemorrhoids in the setting of constipation.