Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stones.
Treatment: Hospital admission.
The health plan denied: Hospital admission.
The determination is: Upheld.

The patient is a female admitted for recurrent nephrolithiasis with obstructive uropathy and acute kidney injury. The patient presented with right flank pain radiating to the groin. Her vital signs demonstrated a temperature of 98.3 Fahrenheit (F), a pulse of 81 beats per minute (bpm), a respiratory rate of 18/minute, a blood pressure of 171/112 millimeters of mercury (mmHg), and an oxygen (O2) saturation of 100 percent (%). The physical exam showed normal neurological findings. The gastrointestinal exam was normal. Her creatinine was 1.34. The white blood cell count was 9.6. A renal ultrasound showed mild right hydronephrosis. The patient was treated with intravenous hydration, and a urology consult was requested. The patient underwent stone fragmentation and extraction with placement of a right ureteral stent. The urine culture grew multiple bacterial morphotypes without a specific infection identified. The patient was then discharged and recommended to follow up with urology in one week.
At issue is the medical necessity of the hospital admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of hospital admission is not medically necessary for this patient.
According to Up to date, 2023:
"Many patients with acute renal colic can be managed conservatively with pain medication and hydration until the stone passes (algorithm 1). In general, patients can be managed at home if they are able to take oral medications and fluids. Hospitalization is required for those who cannot tolerate oral intake or who have uncontrollable pain or fever. Urgent urologic consultation is warranted in patients with urinary tract infection, acute kidney injury, anuria, and/or unyielding pain, nausea, or vomiting."
The patient in this case had a known history of nephrolithiasis status/post lithotripsy and was found to have a 6-millimeter (mm) stone requiring extraction and stent placement. The patient presented for pain management primarily, which could have been performed in the hospital at an alternate level of care. There was no difficulty with oral intake. There was no fever during the hospital stay. The urine culture did not identify a specific urinary tract infection organism. There was no nausea or vomiting. There was no anuria. The patient had mild creatinine elevation of 1.3 (stage 1) which resolved after stone removal. There was no hemodynamic instability or hypoxia. The patient underwent stone removal, and there was no procedural complication.
Also, according to Milliman Care Guidelines (MCG) Renal Colic and Kidney Stones 26th edition, the patient did not have hemodynamic instability, stage II or III acute kidney injury, bilateral obstruction, obstruction with a single functioning kidney, transplanted kidney, severe pain requiring inpatient management, vomiting, urinary tract infection or need for intravenous (IV) hydration beyond initial care. There was no procedural intervention requiring post-procedural inpatient level of care.
Although the patient required services in the hospital setting, the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at an alternate level of care. Therefore, medical necessity of admission has not been established.