Diagnosis: Hydronephrosis
Treatment: Inpatient Hospital Stay.
The health plan denied the requested inpatient stay.
The health plan's determination is upheld.

The patient is a male who was admitted for evaluation of left sided colic. Imaging revealed a proximal left ureteral stone, 6 millimeter (mm), with hydronephrosis. His lab studies were essentially normal, he was afebrile, and he tolerated fluids. He was seen in urologic consultation. no emergency procedures or recommendations were made; rather, the subsequent day, he was taken to the operating room (OR) for Extracorporeal Shock Wave Lithotripsy (ESWL).
At issue is the medical necessity of the inpatient stay.

The health plan's determination is upheld, in whole.

No. The patient, upon presentation to the emergency room (ER), was afebrile. His blood pressure, pulse and temperature were normal. His oxygenation was 99%. His pain was described as moderate, he had no relief with outpatient nonsteroidal anti-inflammatory drugs (NSAIDs). He had no significant medical comorbidities. He was admitted for intravenous (IV) fluids and pain control; he underwent uneventful ESWL within 24 hours of admission and was discharged.
ESWL is typically done as an outpatient. The patient did not receive acute inpatient hospital level of care for his stay and should have been managed under observation criteria. The patient may have been safely discharged to home management and returned the subsequent day for treatment or may have been admitted for close observation without admission. No emergent care nor hospital level of care was provided. The patient had stable vitals, controlled pain, and he tolerated orals. Hospital admission did not meet standard of care of necessity; observation would have been appropriate.