Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a male with no significant past medical history who presented to the emergency department for evaluation of blood in his urine with a fever that started two days before the presentation. The patient described a right flank pain, which was moderate in intensity without modifying factors. The patient noticed an increase in urinary frequency. When seen by the admitting physician, the patient denied headache, chest pain, shortness of breath, cough, abdominal pain, changes in bowel habits.
The patient appeared to be a well-developed, well-nourished male who was in no acute distress. The head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops. His lungs were clear to auscultation without wheezes, rales, or rhonchi. The abdomen was soft, non-tender to palpation, with normal bowel sounds, without guarding or rebound. The rest of his physical exam was unremarkable. While in the emergency department the patient received treatment with Ceftriaxone.
His liver function tests were normal. The urinalysis was positive for a large amount of blood.
He was subsequently admitted to the medical service for further evaluation and treatment. In the hospital, the patient underwent a computed tomography (CT) scan of the abdomen and pelvis. The CT scan demonstrated an unremarkable appearance of the kidneys. There was mildly apparent gallbladder wall thickening. There was diverticulosis without evidence of diverticulitis. The patient had patchy scattered lucencies throughout the skeletal structure. Further evaluation with nuclear medicine was recommended. The bone scan was done. The study was abnormal; however, the differential diagnosis was broad. Therefore, the patient was recommended a magnetic resonance imaging (MRI) scan of the lumbar spine to be performed as an outpatient.
In the hospital, the patient was seen by a urologist who recommended outpatient cystoscopy and a 14-day course of antibiotics. During the hospital stay the patient remained in a stable clinical condition and was discharged home with oral antibiotics.
At issue is the medical necessity of the Inpatient Hospital Admission.

The health plan's determination of medical necessity is upheld in whole.
No, the requested health service/treatment of Inpatient stay was not medically necessary for this patient.
The patient did not have sepsis at the time of presentation according to the review of systemic inflammatory response syndrome (SIRS) criteria. The patient remained hemodynamically stable at the time of the presentation and throughout the entire admission. There was no documentation that the patient had persistent nausea or vomiting precluding him from taking oral antibiotics. There was no indication that the patient was immunocompromised or had new coagulopathy. The urinary tract infection was not associated with acute renal failure. Neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care. Overall, the patient remained in stable clinical condition and did not require diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Therefore, the Inpatient Hospital Admission was not medically necessary for this patient.