Diagnosis: Flank pain.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female. She presented to the hospital with complaints of right flank pain. Her associated symptoms include dysuria and back pain. Her past medical history is significant for kidney stones. On presentation, the patient was afebrile and hemodynamically stable. Examination noted right CVA (costovertebral angle) tenderness. Labs were grossly normal other than an abnormal UA (urinalysis). CT (computed tomography) scan showed an 8-millimeter obstructive calculus in the mid to distal right ureter with mild hydronephrosis. The patient was admitted to the hospital on inpatient status and urology was consulted. The patient underwent ureteroscopy with laser lithotripsy and was discharged home. The medical necessity of the patient's inpatient admission is under review.

The Inpatient admission 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. The procedure was not done on an emergent basis, as it was done the next day. The procedure performed is considered a minimally invasive outpatient procedure. As such, in the absence of a "high risk surgical patient," the patient's care did not warrant acute inpatient admission. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.