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202005-128417

2020

United Healthcare Plan of New York

HMO

Genitourinary/ Kidney Disorder

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis Right Ureteral Stone
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department (ED) with complaints of flank pain. He was diagnosed with a 3 millimeter (mm) right ureteral stone 3 days ago. He was afebrile and hemodynamically stable on presentation. Lab results were grossly normal. he was admitted to the inpatient service and his pain was managed. He was discharged the next day with outpatient follow-up. The medical necessity for an inpatient stay is under review.
The inpatient stay was not medically necessary. This patient's 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 do not support the need for acute inpatient care. The patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation.

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