The patient has type 2 diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, aortic valve replacement, and obstructive sleep apnea; the patient presented to the emergency department (ED) with hematuria and L (left) flank pain, as well as diarrhea.

The health plan's determination is upheld. The Inpatient Hospital Admission is not medically necessary for this patient. The patient had no hemodynamic instability, and no active bleeding was noted. His Hgb was stable, and he had no severe anemia. He required no urgent procedures. The record shows the patient reported gross hematuria, but when a foley catheter was placed, no active bleeding was noted. The Hgb was stable overnight, and no gross hematuria was noted that would require continuous bladder irrigation. The serum creatinine increased overnight, but the patient had no significant acute kidney failure requiring inpatient care. The patient had normal vital signs and had no severe electrolyte abnormalities, severe pain requiring inpatient care, cardiac arrhythmias, or other condition that could only be safely managed at the inpatient level of care. Inpatient care is not consistent with accepted standards of medical practice for his condition and is, therefore, considered not medically necessary.