Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient  presented with a history of a fever and diarrhea. Her stool was without blood or mucous. According to the mother, the patient began having high temperatures after receiving vaccines. The mother gave her Tylenol as needed for fevers. She also noted while a normal frequency of wet diapers, the urine began smelling malodorous in the morning on the day prior. She also noted that the patient developed acrocyanosis for a few seconds while sleeping and then had another episode of perioral cyanosis while sleeping for a few seconds. Both issues self-resolved and the mother denied any associated symptoms.

The mother reported that the patient had decreased PO intake. She normally takes 6-7 ounces (oz) Neosure every (q) 3 hours (hrs) but has only been taking 3 oz q 3 hrs. The mother denied the patient ever having symptoms like this in the past. The mother noted that the patient did develop a low grade fever after the last set of vaccines. The mother denied any recent sick/ coronavirus disease (COVID) positive (+) contacts. In the emergency room (ER), the patient had a temperature of 104.6 degrees Fahrenheit and was in no acute distress. The exam was benign with no noted cyanosis. The emergency room (ER) physician in his assessment stated the patient had no signs of sepsis, bacteremia toxicity, was playful at the time of the exam, with no indications for sepsis protocol.

A complete blood count (CBC), comprehensive metabolic panel (CMP), venous blood gas (VBG), urinalysis (UA) /urine culture , Blood culture, and respiratory viral panel (RVP) were all done. She was given a Tylenol suppository times (x) 1, normal saline (NS) Bolus x 1 and Ceftriaxone x 1 due to an elevated lactate. An electrocardiogram (EKG) showed sinus tachycardia.

The patient was admitted to the pediatric floor with a presumptive urinary tract infection (UTI) with high fevers/high lactate requiring hydration and antibiotic administration. The patient arrived in stable condition. The vital signs were stable. The patient remained on intravenous fluids (IVF) throughout the day for hospital day (HD) number (#) 1 but was noted to have improvement in PO intake. The patient remained afebrile since admission. The patient was noted to lose her IV overnight on HD #1 but due to adequate PO intake it was deemed unnecessary to replace. She remained in stable condition on HD#2. She remained in stable condition on HD#2 and HD#3. On HD#3, a urine culture resulted as positive but due to a delay in lab sensitivities it did not result. The patient was transitioned to oral Cefdinir on HD#3 and was deemed stable for discharge with a plan for follow up with her primary medical doctor (PMD) in 1-2 days. The mother was counseled that she would be contacted when sensitivities resulted for potential change of antibiotics.

At issue is the medical necessity of an inpatient stay.

The requested inpatient stay was not medically necessary for this patient.

The patient presented with a high fever and malodorous urine. Her laboratory evaluation was suggestive of a urinary tract infection. She did not have any markedly elevated inflammatory markers, as her WBC was within normal limits, and she did not exhibit any signs or symptoms of sepsis. Her vital signs were stable, apart from tachycardia, when she was febrile, which is to be expected. She responded well to hydration and a dose of IV antibiotics. By the next morning, her PO intake had improved, and her IV fell out and was not replaced. She remained afebrile after admission. She was discharged on a broad spectrum PO antibiotic prior to the sensitivity of her urine culture returning. She could have been monitored overnight and transitioned to outpatient care with close follow up. The Milliman Care Guidelines (MCG) Urinary Tract Infection (UTI), Pediatric clinical indications for admission to inpatient pediatric care state admission is indicated for one or more of the following: infant younger than 2 months, hemodynamic instability, altered mental status that is severe or persistent, bacteremia, persistence or worsening of clinical findings (fever, pain, dehydration, vomiting) despite observation care treatment, parenteral antibiotics needed beyond observation care treatments (patient cannot take oral medications, known or suspected pathogen resistance to oral agents), serious medical comorbidities or immunocompromised state (i.e. type one diabetes mellitus (T1DM), sickle cell disease, chronic systemic corticosteroid use), inability to adhere to outpatient regiment, history of significant uropathy (obstructive defects, moderate to severe vesicoureteral reflux (VUR), previous urologic surgery or instrumentation (i.e. stent placement, endoscopic procedure) or condition that requires drainage procedure such as urinary obstruction, renal or perinephric abscess, emphysematous pyelonephritis, pyelitis, pyonephrosis, acute renal failure, or need for IV hydration support (inability to maintain oral hydration) despite observation care treatment. The patient did not meet any of these criteria. Therefore, an inpatient stay was not medically necessary.