Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department with concerns for dysuria and fever. The pertinent history included recurrent urinary tract infections, benign prostatic hypertrophy, diabetes mellitus, and nephrolithiasis. The initial vital signs revealed a temperature of 102.7 degrees Fahrenheit (F), heart rate (HR) 118, blood pressure (BP) 121/79, respiratory rate (RR) 26, and peripheral capillary oxygen saturation (SpO2) 97% on room air. The initial examination documented the patient as alert, oriented, and without costovertebral tenderness. Initial laboratory testing revealed a white blood cell count (WBC) of 16.79, hemoglobin (Hgb) 13.6, platelets (Plt) 232, sodium (Na) 141, potassium (K) 5.3, carbon dioxide (CO2) 23, blood urea nitrogen (BUN) 20, creatinine (Cr) 1.0, glucose (Glu) 202, and lactate 1.95. A urinalysis revealed pyuria and bacteriuria. Empiric antibiotics and intravenous fluids were administered. The patient was admitted to the hospital with an impression of a complicated urinary tract infection and diabetes mellitus type 2. The treatment plan included intravenous fluids and empiric ceftriaxone. Clinical improvement was observed throughout the day. The assessment and treatment plan remained essentially unchanged. A urine culture grew pan-sensitive Escherichia coli. The patient was discharged with a diagnosis of complicated cystitis.
At issue is the medical necessity of an inpatient stay.

Yes, based on the clinical documentation provided, evidence-based literature and standards of care, an acute inpatient level of care was medically necessary for the entire admission.
Colgan et al. note that urinary tract infections are the most common bacterial infections in women. Most urinary tract infections are acute uncomplicated cystitis identified by increased urinary frequency and dysuria in an immunocompetent woman who has no comorbidities or urologic abnormalities. Thus, characteristics of patients with an uncomplicated urinary tract infection would include a person who has no comorbidities, immunocompetent, without known urologic abnormalities, not pregnant, and premenopausal. On the contrary, patients who would be considered to have a complicated urinary tract infection would include those with a history of childhood urinary tract infections, immunocompromised state, preadolescent or postmenopausal, pregnant, male sex, underlying metabolic disorders such as diabetes mellitus, or known urologic abnormalities such as stones, stents, indwelling catheters, neurogenic bladder, or polycystic kidney disease.[1]
In addition to the aforementioned characteristics, Gupta et al. notes that findings of involvement beyond the bladder such as fever, chills, rigors, significant fatigue or malaise, flank pain, costovertebral angle tenderness, and/or pelvic or perineal pain in men would be suggestive of an acute complicated urinary tract infection. The importance of classification is that those deemed to have a complicated infection are at a higher risk for a more serious infection and thus are managed differently and/or more aggressively.[2]
In this particular situation, the patient had a history of benign prostatic hypertrophy, diabetes mellitus, and recurrent urinary tract infections and presented with a fever, tachycardia, tachypnea, leukocytosis, pyuria, and bacteriuria. The admitting physician had an impression of a complicated urinary tract infection and empiric antibiotics were initiated. Significant clinical improvement was achieved with appropriate intervention. Moreover, clinical indications for admission to inpatient care were met. The patient met the aforementioned criteria for a complicated urinary tract infection as well as an anatomical abnormality (benign prostatic hypertrophy) that places the patient at increased risk for systemic illness.[3]