Diagnosis: Left flank pain.
Treatment: Hospital admission- emergency, 3 days.
The insurer denied coverage for the hospital admission- emergency, 3 days.
The denial is upheld.

This is a male patient with a history of an immunocompromising illness, Hepatitis B, hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) with complaints of left flank pain. He was admitted for worsening left flank pain. His vital signs in the ED were: blood pressure 118/78, pulse 98, temperature 99.2, respiration 18, and oxygen saturation 97%. The patient's laboratory results were remarkable for elevated creatinine levels. The patient's computed tomography (CT) scan of the abdomen was negative for acute process. The patient's ultrasound of the kidney was unremarkable. The patient was started on intravenous fluid and pain medication, his condition responded appropriately. His creatinine level improved on day 2 of admission. He was discharged on day 3 of admission in a stable condition.

Based on the review of the medical record, the patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or sign of intrinsic kidney failure, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain. The patient was able to tolerate oral diet and did not require total parenteral nutrition. His condition responded appropriately to intravenous fluid within 48 hours. There is no evidence-based literature [to support that] inpatient level of care was medical necessary. His condition could have been treated safely under a lower level of care.

The hospital admission- emergency, 3 days is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for the hospital admission- emergency, 3 days is not substantiated. The insurer's denial should be upheld.