Appeal type: Medical necessity
Decision: Overturned

Diagnosis: UTI
Treatment: Inpatient admission
The inpatient admission was medically necessary.
Five days before presentation, the patient developed mild cold symptoms. She was drinking well and was initially afebrile. Three days before, she spiked a fever to 105. She was taken to the pediatrician for evaluation. Laboratory evaluation revealed leukocytosis with white blood cell (WBC) count to 25.9K. No blood culture was obtained. Urine dip from a bagged specimen was positive for nitrites, so she was given a dose of ceftriaxone for presumed urinary tract infection and sent home. 
The patient continued to spike fevers at home, to 103 on the morning of presentation. She was not eating as well, and had two episodes of vomiting the night prior. She was fussy and irritable. She returned to the pediatrician where repeat complete blood count (CBC) revealed WBC count of 28.8K. The patient was subsequently transported to the ED for further evaluation. Of note, she had only received her two-month vaccinations and MMR/influenza/varicella at one year of age, so was significantly behind and unprotected against pneumococcus. 
Vital signs included temperature 37.7, heart rate 161, respiratory rate 30, and blood pressure 107/70. Examination was significant for no acute distress, crying with tears, non-erythematous throat and ears, clear lungs, benign abdomen, regular heart rate, good perfusion, and non-focal neurologic exam. Laboratory evaluation revealed significant leukocytosis with WBC count of 33.1K (65% neutrophils), mild anemia (hemoglobin 10.3), and significantly elevated C-reactive protein (CRP) (22.5). The mother refused a urinalysis. She was treated with a normal saline bolus and Zofran and given an oral challenge. Because of her essentially unvaccinated status, persistent high fevers despite the outpatient ceftriaxone, and significant rise in WBC count, she was given a second dose of ceftriaxone with plans to admit her for further care. The mother wanted to wait to see how the patient was in an hour. The patient was re-evaluated with determination that admission was necessary for treatment of presumed pyelonephritis. Chest x-ray and viral respiratory panel were ordered prior to transfer. Chest x-ray revealed moderate peribronchial thickening that may be related to a viral process or reactive airway disease. 
The patient was admitted for management of clinical dehydration and presumed pyelonephritis. Admission orders included continuation of ceftriaxone with addition of ampicillin to cover enterococcus, intravenous (IV) fluids, and antipyretics. Repeat CBC the next day revealed improvement in leukocytosis (20.5K) with persistent anemia (hemoglobin 9.0) and improved CRP (11.1). Viral panel was ultimately negative. Renal ultrasound was performed and was significant for possible duplex right renal collecting system, no dilation of bilateral collecting systems, and a small amount of free fluid in the vagina possibly related to reflux of urine. Urology was consulted to follow-up on the urine in the vagina, recommending voiding cystourethrogram (VCUG) only if she were to get a second urinary tract infection. 
Following admission, the patient remained afebrile with improving appetite. All cultures remained negative, and the urine culture from the pediatrician office was negative as well. She was discharged to complete five days of cefdinir and amoxicillin. 
This patient was treated with ceftriaxone in the outpatient setting, but remained febrile with worsening indices of infection on blood work both in the office and in the ED. Further, she was not fully vaccinated, increasing the potential for serious bacterial infection. In the ED, she was given additional ceftriaxone and IV fluids, with no indication that she tolerated an oral challenge. Acute inpatient hospitalization was medically necessary and appropriate for this child to provide standard of care treatment for presumed pyelonephritis versus other serious bacterial infection.