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

The patient has a history of obesity and presented to the emergency room (ER) with abdominal pain and associated diarrhea. The patient was afebrile and hemodynamically stable on presentation. The review of systems was normal and the physical examination showed right abdominal tenderness. Lab results were grossly normal other than a creatinine of 1.67. A computed tomography (CT) showed an obstructing proximal ureteral stone. The patient was admitted. A urology consult recommended medical expulsive therapy. The patient had an uneventful hospital course and was discharged.
At issue is the medical necessity of an inpatient stay.

No. The inpatient stay was not medically necessary. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The 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 does not suggest the need for acute inpatient care. 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. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.