Diagnosis: Bilateral nephrolithiasis

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld.

This is a female with no significant past medical history. She presented to the emergency department with complaints of abdominal and flank pain. She was admitted to the pediatric unit that day for bilateral nephrolithiasis. She improved with treatment and discharged the next day. The insurer has denied coverage for the inpatient admission as not medically necessary. They noted that she had kidney stones which she was able to pass, after she was admitted for abdominal/back pain. They felt that the patient's medical needs could have been treated in an observation setting for up to 48 hours. The appeal on behalf of the hospital is noted and was read in detail. The patient's imaging showed a 0.4 cm (centimeter) obstructing calculus in the left lower pole and a 0.3 cm calculus within the right ureterovesicular junction. The patient received intravenous fluids, Toradol 15 mg (milligrams) intravenous, and morphine 4 mg intravenous in the emergency department. She passed the (likely) right distal ureteral stone the following AM (morning). Per MCG (Milliman Care Guidelines) Health (25th) renal colic and kidney stones, the patient fails to meet clinical indications for an admission to inpatient care. These include hemodynamic instability, bilateral obstruction, acute renal failure, and obstruction in a patient who has only one (solitary) kidney. The patient had only her right kidney obstructed by a small distal stone which passed in < (less than) 24 hours with medical management.

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

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