Diagnosis: Left Ureteral Stone/ Hydronephrosis
Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

This patient who has a past medical history of type 2 diabetes, hypertension, and chronic pancreatitis presented to the emergency department complaining of chills and left flank pain radiating to left groin. The patient had been to the same emergency department 2 days before and was diagnosed with 5 millimeter (mm) obstructing left ureteral stone. The patient was discharged then on Flomax and pain medications but returned with worsening symptoms. Exam was positive for left costovertebral angle tenderness, left upper quadrants / left lower quadrants abdominal tenderness. The patient was admitted with diagnosis of left ureteral stone/ hydronephrosis and scheduled for cystoscopy, left ureteroscopy with laser lithotripsy left stent placement. The patient was given intravenous fluids, intravenous antibiotics, Flomax, pain medications as needed. The patient's symptoms improved; it was determined that he was stable for discharge home on Flomax/Bactrim with outpatient follow up care.

Per Milliman Care Guidelines (MCG) Health (25th) Renal Colic and Kidney Stones RRG: patient fails to meet clinical indications for admission to inpatient care.

These include:

- Hemodynamic instability
- Acute renal failure (Stage 3 AKI [acute kidney injury])
- Bilateral obstruction
- Urinary Tract Infection
- Severe pain requiring acute inpatient management
- Obstruction with a single functioning kidney or a transplanted kidney

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

The inpatient hospital stay was not medically necessary for this patient.

The insurer's denial of coverage for inpatient hospital stay is upheld. Medical Necessity is not substantiated.