Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stone, Urinary Tract Infection
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.   

This is a male patient with history of thyroid cancer, hypothyroid, anxiety/depression, status post thyroidectomy and left knee surgery.  The patient presented to the hospital with complaints of worsening right lower quadrant (RLQ) abdominal pain radiating to groin/testicles. His presenting vital signs revealed blood pressure (BP) 164/98, Temperature 97.6, Heart Rate of 101, Respirations 18, SpO2 of 98% on room air. On exam, the patient had mild RLQ tenderness. The patient's urinalysis showed trace blood and leukocyte esterase. The patient's bloodwork showed elevated white blood cell count of 16.7K but normal BUN/Creatinine of 20/1.0. The patient's scrotal ultrasound showed bilateral hydroceles.  The patient was treated with intravenous (IV) fluids, IV Rocephin, and oral (PO) medications.  The patient's computed tomography (CT) scan revealed right mild hydro-nephrosis due to a 4-5 mm stone just proximal to right ureterovesical junction (UVJ).  The patient was admitted for a kidney stone and urinary tract infection (UTI).  After treatment with IV fluids, IV Rocephin, Flomax, and oxycodone, the patient clinically improved and was cleared for discharge home.

As per MCG Health (24th Edition) Renal Colic and Kidney Stones, inpatient admission is indicated for one or more of the following: (1) hemodynamic instability; (2) acute renal failure; (3) bilateral obstruction; (4) obstruction with single functioning kidney; (5) transplanted kidney with obstruction; (5) severe pain requiring acute inpatient management; (6) vomiting that is severe or persistent; (7) urinary tract infection; (8) need for IV hydration support despite observation care treatment; (9) stone removal procedure needed requiring inpatient admission (e.g. postprocedural care need require inpatient level of care). However, it also indicates that lower level of care, such as observation is appropriate for patients with one or more of the following: (1) vital sign abnormality; (2) insufficient pain relief in emergency department setting; (3) suspected infection (e.g., fever, pyuria); (4) inability to maintain oral hydration (e.g. due to vomiting) that persists despite emergency department treatment; (5) acute change in kidney function (e.g. rise in creatinine). 

As per MCG Health (24th Edition) Urologic Disease, inpatient admission would have also be indicated for this patient if this patient remained to have hydronephrosis despite observation level of care. 

Based on the review of the medical record, this patient was suspected to have urinary tract infection in the setting of kidney stone obstruction. However, the patient was afebrile, hemodynamically stable with normal renal function, and did not require emergent stone removal procedure that required inpatient admission. This patient had pain but not severe enough to cause vomiting and dehydration. The patient could have been provided intravenous fluid, antibiotic and pain management at the observational level of care, and then be transitioned to oral medications. If the patient had failed observational level of care, inpatient admission could have then been considered medically necessary. 
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient admission should be upheld.  The medical necessity is not substantiated.