Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/ Kidney Disorder/Urinary Tract Infection/UTI.
Treatment: Inpatient Hospital Admission.
The health plan denied: Inpatient Hospital Admission.
The determination is: Overturned.

At the time of admission, the patient was a male infant who was referred to the emergency department (ED) because of a positive urine culture.
He had been seen in the ED previously for a fever that had continued for 3 days. A urine sample was obtained at that time, and the urinalysis revealed leukocyte esterase and nitrates. He started on oral Amoxicillin and was discharged home. On the day of presentation, his urine culture grew gram negative bacilli. He had continued to have fevers, as well decreased oral intake and fussiness, and therefore, he was referred back to the emergency department for care.
His past history is significant for a prior urinary tract infection in September, with left sided hydronephrosis noted at that time.
In the ED, he had an ill appearance. Laboratory values were significant for a c-reactive protein of 23.5, a white blood count of 16.4, and leukocyte esterase in his urine. A renal ultrasound was obtained which revealed debris within the bladder and left renal pelvis. His urine culture grew >(more than)100,000 colonies of Escherichia Coli (E. Coli). He was subsequently admitted to the hospital for treatment with parenteral antibiotics for pyelonephritis.
In the hospital, he was treated with intravenous Ceftriaxone. After 24 hours, he became afebrile and was transitioned to oral Cefdinir. His oral intake improved, and he was felt to be stable for discharge with follow up as an outpatient.
At issue is the medical necessity for the inpatient admission.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of an inpatient admission was medically necessary for this patient.
This is a young infant who presented with pyelonephritis. He had been treated as an outpatient, but he continued to have fever and decreased oral intake. He was ill appearing at the time of presentation, had elevated inflammatory markers, and had a history of urinary tract infection and hydronephrosis. He therefore required hospital admission for prompt administration of parenteral antibiotics, along with close monitoring for potential deterioration of clinical status.
The decision making at the time of admission for this patient was consistent with his young age, the presence of pyelonephritis with symptoms that continued despite outpatient therapy, and the need for prompt treatment with parenteral antibiotics to avoid further morbidity.
Usual indications for hospitalization for parenteral therapy for pyelonephritis include age <(less than) 2 months, toxic appearance, and failure to respond to outpatient therapy. He therefore required hospitalization for appropriate treatment with parenteral antibiotics and monitoring.
This infant had pyelonephritis and was ill appearing at the time of presentation. This patient had fever and decreased oral intake and had a history of hydronephrosis. Based on the guidelines, hospitalization is indicated for patients with toxic appearance and failure to respond to outpatient therapy, both of which this patient had. The patient required hospitalization for appropriate treatment with parenteral antibiotics and monitoring.