Kidney Stones: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for treatment with a pain management specialist and either Dilaudid or morphine. The Centers for Disease Control and Prevention (CDC) guidelines state that, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.” Similarly, the Federation of State Medical Boards guidelines noted that, “Continuation, modification or termination of opioid therapy for pain is contingent on the clinician’s evaluation of (1) evidence of the patient’s progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion.” In addition, the American Socie…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. According to researchers, a referral to the emergency department (ED) is recommended for “patients who have an unknown duration or trajectory of elevated creatinine, or if there is concern that the condition may not be rapidly reversible with simple interventions (such as volume expansion or removal of a potential nephrotoxin).” In this case, the patient presented to the ED with acute kidney injury and pain. The patient’s kidney function, as represented by his creatinine, was elevated beyond normal values. A computed tomography (CT) scan of the patient’s abdomen and pelvis revealed right hydronephrosis and inflammation adjacent to the right collecting system.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services that were provided on 12/17/16 to 12/23/16. An undated invoice states that the enrollee was in the hospital from 12/9/16 through 12/16/16 and 12/17/16 through 12/23/16. According to the patient’s IMR application dated 2/19/19, she was traveling in Vietnam and required emergency surgery to alleviate kidney stones. Detailed medical information is not available for review. There is a translation of documents called a “List of Examination and Treatment Charges” for admission from 12/9/16 to 12/16/16, which states that emergency admission was for kidney stones. There is documentation about surgery, intensive care unit (ICU) care services, and ultrasound.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Actiq, fentanyl citrate 1600 mcg.Findings: The physician reviewer found that the medical records have shown the patient to have chronic non-malignant pain. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for kidney stones was denied, the published record says the denial is worth fighting.