Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right flank pain, pregnancy.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient who is gravida (G) 5 para (P) 4 who presented with right flank pain. The patient reported this to be ongoing throughout her pregnancy. She was noted to have swelling of the right kidney and denied any history of kidney stones. She was scheduled for stent placement with urology. The patient presented to labor and delivery due to increased severity of her symptoms with pain at 9 and 10 at the most severe that was localized to the right flank. She reported that the pain was sharp in quantity and intermittent duration. This was not alleviated with over-the-counter medications. She was reporting chills, nausea and vomiting, and dysuria. She denied a headache, chest pain, shortness of breath or obstetric complaints. She had no contractions, leakage of fluid or vaginal bleeding. She was reporting good fetal movement.

The review of systems was noted for dysuria and flank pain but was otherwise negative. Her cervix was noted to be 2 centimeters (cm) long and minus (-) 3 station. The patient's prior history was noted for an ultrasound demonstrating a vertex presentation with a posterior placenta and an estimated fetal weight of 4 pounds (lbs) 13 ounces (oz) with a normal amniotic fluid index of 14.97. The biophysical profile (BPP) was reassuring at 8 of 8. The physical exam was noted for the patient having right-sided costovertebral angle (CVA) tenderness to light palpation. The remainder of her exam was noted to be normal. Fetal testing was noted to be reassuring and category 1 on fetal monitoring.
The patient was noted to have a diagnosis of kidney stone complicating pregnancy and was admitted for intravenous (IV) hydration and pain management for severe right-sided flank pain in the setting of known right hydronephrosis. She was to have labs and a renal ultrasound performed. She was started on lactated Ringer's at 125 cubic centimeters (cc) per hour and pain management with Tylenol as needed with Dilaudid was ordered. The patient was given a nonstress test twice daily and remained nothing by mouth after midnight. The maternal fetal status was monitored and straining of urine was planned for a stone.

She was scheduled for stent placement and the nonstress test (NST) had been reactive overnight. The patient's vital signs remained stable and she was afebrile. The patient had an ultrasound that had been performed which noted both kidneys to be in the correct position and there was moderate to severe right hydronephrosis noted with bilateral ureteral jets not visualized at that time. The patient was an add on for ureteral stent placement in the operating room due to the worsening right-sided flank pain. The patient underwent uncomplicated placement of a right-sided ureteral stent and had cystoscopy performed. Ultrasound guidance was used for the stent placement at time of surgery. The right ureteral stent was placed under ultrasound guidance without any intraoperative complications. The patient was noted to have resolution of the CVA tenderness on the right side but reported significant suprapubic cramping and pain. The patient did not have any contractions and nonstress testing was reassuring. The pain was 6 at 10 in severity and was improved with Tylenol. The patient was counseled as to bladder spasm in this presentation due to stent placement. She had good fetal movement with no loss of fluid or vaginal bleeding.

At issue is the medical necessity of an inpatient stay.

Based upon a review of the medical records and the peer-reviewed literature, there was no medical necessity for admission to acute inpatient level of care for right flank pain and hydronephrosis in this case.

The patient was noted to have a scheduled plan for stent placement for right renal hydronephrosis. She was managed with pain medication and intravenous (IV) fluid. The patient underwent an ultrasound. She remained hemodynamically stable and afebrile. There was no sign of renal failure or dysfunction. She underwent stent placement via ultrasound guidance and cystoscopy without complication on the date of discharge. In this case, the services provided would be provided at the observation level of care. Both IV hydration and pain management can be provided at a lower level of care.

Mild to moderate hydronephrosis is most consistent with normal pregnancy physiology as there is no obstruction present. Most (75 to 85 percent) stones pass spontaneously due, in part, to the normally dilated urinary tract in pregnant women. Pain medications can be used until passage takes place. In patients who fail to spontaneously pass the stone and who develop urinary tract infection, persistent urinary obstruction, or persistent, severe pain, ureteroscopy with laser lithotripsy may be an option. Small caliber ureteroscopes minimize or eliminate the need for concomitant fluoroscopic monitoring. If additional monitoring is needed, ultrasonography (no ionizing radiation) or pulsed fluoroscopy (minimal ionizing radiation) can be used. In this case, there was no obstruction or renal failure and thus, these interventions were not necessary. In this case, there is no support for acute inpatient admission given the lack of infection and lack of obstruction of the urinary tract. Rather, the patient could have been managed at a lower level of care for pain control and stent placement. The peer-reviewed literature supports the use of imaging and observation care in this setting. This care plan for outpatient management is supported by the American Urological Association.