Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented to Glens Falls Hospital emergency department (ED) with complaints of right upper quadrant abdominal pain with pressure and burning at urination. The patient was admitted for management of right nephrolithiasis with obstructing stone. The patient received intravenous (IV) antibiotics, was evaluated by Urology and underwent a right cystoscopy ureteral stent insertion. Vital signs were unremarkable.

Treatment rendered was appropriate; however, classification as inpatient status was not medically necessary as treatment could have been managed at a lower lever of care such as outpatient care. Inpatient care was not medically necessary as the patient had normal vital signs, was not experiencing renal failure, did not exhibit blockage of both kidneys, did not experience uncontrollable pain or nausea and vomiting, and did not have a stone removal procedure that required inpatient management. Therefore, the inpatient admission is not considered medically necessary for this patient.

"In this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received computed tomography (CT)scans, in a cohort representing 15-20% of all US emergency department (ED) visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT." (Schoenfeld, E. M., Pekow, P. S., Shieh, M. S., Scales, C. D., Jr, Lagu, T., &amp; Lindenauer, P. K., 2017).

Fontenelle, L. F., &amp; Sarti, T. D. (2019), "Kidney stones are a common disorder, with an annual incidence of eight cases per 1,000 adults. During an episode of renal colic, the first priority is to rule out conditions requiring immediate referral to an emergency department, then to alleviate pain, preferably with a nonsteroidal anti-inflammatory drug. The diagnostic workup consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal, such as urinary infection or a stone larger than 10 millimeters (mm). Conservative management consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging within 14 days to monitor stone position and assess for hydronephrosis. Asymptomatic kidney stones should be followed with serial imaging, and should be removed in case of growth, symptoms, urinary obstruction, recurrent infections, or lack of access to health care. All patients with kidney stones should be screened for risk of stone recurrence with medical history, basic laboratory evaluation, and imaging. Lifestyle modifications such as increased fluid intake should be recommended for all patients, and thiazide diuretics, allopurinol, or citrates should be prescribed for patients with recurrent calcium stones. Patients at high risk of stone recurrence should be referred for additional metabolic assessment, which can serve as a basis for tailored preventive measures."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.