The patient is a male who presented to the emergency room with complaints of left flank pain. Past medical history is significant for right kidney stone status post lithotripsy. Medical history is also significant for cardiomyopathy, diabetes, obesity, hypertension, congestive heart failure (CHF) and atrial fibrillation. He was afebrile and hemodynamically stable on presentation. Examination revealed trace edema and left costovertebral angle (CVA) tenderness. Computed tomography (CT) scan showed a left 5 millimeter (mm) ureterovesical junction (UVJ) stone with moderate hydronephrosis. Labs showed a white blood cell (WBC) count of 12.7 and a creatinine of 1.5. The patient was admitted on the inpatient service. The patient passed a stone. He was discharged the next day in a stable condition.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient didn't present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care status for this patient's clinical presentation was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.