Diagnosis: Hydronephrosis

Treatment: Inpatient Hospital Admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient has a history of hypertension (HTN), and kidney stent procedure. The patient presented to the Emergency Department (ED) complaining of right flank pain, nausea/vomiting, and heart rate 111 beats per minute. He was noted to have elevated white blood cell (WBC) count and serum creatinine. Computed Tomography scan revealed right hydronephrosis consistent with right ureteropelvic junction (UPJ) obstruction. Urinalysis was sent, the patient was started on intravenous (IV) Rocephin and the patient was admitted for a urinary tract infection (UTI). Urology recommended keeping the patient nothing by mouth (NPO) for possible procedure. Bladder scan revealed post void residual (PVR) of 100 milliliter (ml). Renal scan done revealing 30 percent (%) function right kidney, 70% on the left. The patient improved, and did not require a stent placement. The patient was stable for discharge home.

The insurer denied coverage for the inpatient hospital admission as not medically necessary. They noted the UTI vital signs (VS) were stable, elevated WBC count is noted. There was no indication that the patient did not improve after observational treatment and the patient could have been safely treated at the observation level. The appeal on behalf of Brookdale University Hospital and Medical Center is noted and read in detail.

This patient has a history of right pyeloplasty in for right Ureteropelvic junction (UPJ) obstruction. After such surgery, the collecting system will almost have a hydronephrotic appearance on CT scan or renal ultrasound, and usually only a Lasix renal scan can determine if the obstruction still exists in that kidney.

Per Milliman Care Guidelines (MCG): Urinary Tract Infection (UTI) and Urologic Disease - GRG, the patient fails to meet clinical indications for admission to inpatient care. The patient's urinalysis was abnormal in the Emergency Department but all blood/urine cultures were negative for acute infection.

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient. The inpatient hospital admission was not medically necessary.
The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.