Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney Stone
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a male with a medical history significant for nephrolithiasis who presented to the emergency department with right flank pain. His flank pain started approximately 3 weeks before his presentation. He was seen by a urologist as an outpatient and underwent a computed tomography (CT) scan of the abdomen, which demonstrated renal stones. The patient was previously scheduled for a lithotripsy. However, his flank pain worsened to the point that it was not relieved with Ibuprofen and Tylenol number (#)3. This prompted the patient to come to the emergency department. The patient reported that the right flank pain radiated to his groin. He reported some chills but denied dysuria. He previously had hematuria, which resolved.

The patient denied nausea or vomiting. The review of systems was negative for chest pain, shortness of breath, or cough. Upon the physical examination, the patient's temperature was 99.2 degrees Fahrenheit, heart rate was 87 beats per minute (bpm), respiratory rate was 18 breaths per minute, blood pressure 135/68, and his oxygen saturation was 99 percent (%) on room air. The patient was alert, well-oriented, and in no distress. His skin was warm and dry. The head, eyes, ears, neck, throat (HEENT) examination was within normal limits. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. His lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient's abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. Upon the neurologic examination, the patient was alert and oriented times 4 with no focal deficits. There was no pedal edema or tenderness.

The laboratory evaluation revealed that his sodium was 135, potassium 4.3, chloride 100, bicarbonate 25, blood urea nitrogen (BUN) 22, creatinine 2.07, and his glucose was 101. The white blood cell count was 10.4, hemoglobin 15.0, hematocrit 41.7, and his platelets were 211. The patient has 77.5% neutrophils on the differential. The urinalysis was negative for protein, glucose, nitrite, or leukocyte esterase. The patient had zero white blood cells in the urine and 4 red blood cells. The computed tomography (CT) scan of the abdomen and pelvis demonstrated a 1.2-centimeter (cm) stone in the proximal right ureter with associated right-sided hydronephrosis. There was a large right renal cyst that was peripheral calcification.

The patient was admitted to the hospital with acute kidney injury, renal calculi hydronephrosis, and renal cyst. The patient was positive for influenza. He received treatment with intravenous fluids, Ceftriaxone, and Flomax. The patient was seen by a urologist who diagnosed the patient with abstracting stone.  

Based on the circumstances presented, the admission at the acute inpatient level of care was medically necessary for this patient. The patient had stage II acute kidney injury, which is a graded system used to describe the severity of acute kidney injury (AKI). This is an indication for admission at the acute inpatient level of care based on the renal colic and kidney stone Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 26th Edition criteria. According to these guidelines, admission at the acute inpatient level of care is indicated for patients with renal colic and kidney stones who present with acute kidney injury stage II. Stage II acute kidney injury (AKI) is the second stage of a graded system used to describe the severity of AKI. It is defined as an increase in serum creatinine level of 2 to 2.9 times the patient's baseline level or a decrease in urine output to less than 0.5 milligram per kilogram per hour (ml/kg/hour) for 12-24 hours. In this clinical case, the patient's creatinine was between 2 and 2.9 for at least 2 days of the hospitalization, consistent with stage II acute kidney injury. 

The health plan's determination of medical necessity is overturned in whole.