Diagnosis: Hydronephrosis and obstructing stone

Treatment: Inpatient admission, diagnostic testing and intravenous evaluation.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Room and was admitted with complaints of left flank and groin pain. A CT scan revealed left hydronephrosis and an obstructing stone at the left uretero vesicular junction (UVJ). The white blood cell (WBC) count was 11,000. The patient was admitted to Urology and treated with intravenous (IV) fluids/IV antibiotics. The patient improved. A renal ultrasound was performed on 8/20/18 showing resolution of the left hydronephrosis and no evidence of stone. She was discharged home with outpatient Urology follow-up.

The insurer has denied coverage for the full hospital admission as not medically necessary. In their final adverse determination letter, they note that the patient was found to have a kidney stone. They stated that the hospital care provided could have been given without a full admission. This may include monitoring up to 23 hours. Urology wanted to discharge the patient home earlier, but the patient declined to be discharged until the following morning.

Per MCG Health (22nd Edition) Renal Colic and Kidney Stones RRG, the patient fails to meet clinical indications for admission to inpatient care. The patient had no urinary tract infection, acute renal failure, bilateral obstruction, or hemodynamic instability. Admission was not medically necessary.