Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Groin Pain and Blood in Urine
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with history of bilateral non-obstructing stones and left six millimeter obstructing stone diagnosed previously when she was seen for left flank discomfort. The patient presented complaining of worsening pain and underwent bilateral stent placement and bilateral lithotripsy. She then presented two weeks later for care of worsening right, less severe left flank pain. She reported being seen by her primary care physician (PCP) five days prior and was started on ciprofloxacin for possible urinary tract infection (UTI), but the urine culture returned negative. At that time, there were symptoms of lower abdominal pressure, bilateral flank tenderness and hematuria. She denied fevers/chills. The patient was noted to have pressure to the right and left groin and mild right and left lower quadrant tenderness. The pain improved from ten out of ten (10/10) to three to four out of ten (3-4/10) with Toradol. The patient was noted to be afebrile (98.4) and hemodynamically stable.  Her white blood cell count was normal, creatinine was 1.18 (mildly elevated) and blood urea nitrogen was 21. A urinalysis demonstrated large leukocyte esterase, large blood, 15 to 30 red blood cells per high power field, 10 to 15 white blood cells per high power field, nitrite negative and few bacteria. She received Rocephin in the emergency room. Computed tomography (CT) scan of the abdomen and pelvis demonstrated stents in place, no hydronephrosis or stones noted, no perinephric stranding, and no acute abdominal/pelvic pathology.  The patient requested stent removal. She was admitted to inpatient service. Urology consulted and indicated they would perform stent removal if the urine culture negative. The patient remained afebrile and hemodynamically stable, urine culture returned as no growth and stent was subsequently removed.  The patient was discharged to home later that day; the impression was ureteral stent colic.

The proposed treatment was not medically necessary.
The proposed acute inpatient hospitalization was not medically necessary. This patient underwent bilateral stent placement and lithotripsy for bilateral stones approximately two weeks prior to presentation. She had been seen five days prior to admission and was started on ciprofloxacin for presumed urinary tract infection (UTI) and culture returned negative. The patient had no fever, was able to hold down food, and was hemodynamically stable on presentation. A computed tomography scan demonstrated no stones, hydronephrosis, stents in good position and no perinephric stranding. A urinalysis was suspicious for a urinary tract infection however was consistent with prior lithotripsy and stent irritation. Her white blood cell count was normal. She received a dose of Rocephin in the emergency room and was admitted to acute inpatient service for possible pyelonephritis. The patient was seen by urology who recommended either outpatient stent removal or removal of stent inpatient if urine culture negative. Urine culture was negative, the stents were removed and the patient was discharged to home. 

The acute inpatient hospitalization was denied as not meeting Milliman Care Guidelines (MCG).  The patient was hemodynamically stable, afebrile, able to tolerate oral intake and at the time of presentation to the emergency department, had not been reported to have been taking her oral pain medications. The patient responded to Toradol with pain improvement. She had no signs of sepsis, her white blood cell count was normal, she had a computed tomography without acute pathology and thus did not warrant acute inpatient admission and could have been managed at a lower level of care with additional therapies for her stent colic. Furthermore, there were no identified co-morbidities identified that warranted acute inpatient admission.