Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection/UTI
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary.
The health plan's determination is upheld.

The patient is a male with underlying hypertension who presented to the emergency department (ED) with four days of fevers and myalgias, accompanied by dysuria and nausea. He attempted to control the symptoms with Tylenol and ibuprofen without improvement. The dysuria continued, and the urine output decreased, so the patient came to the ED to be assessed. He denied chest pain, shortness of breath, hematuria, or diarrhea.
His vital signs in the ED included a temperature of 100.4 Fahrenheit, a pulse rate of 93 beats per minute, respirations of 16/minute, and a blood pressure of 142/76 millimeters of mercury. A urinalysis was completed in the ED, showing more than 100 white blood cells, positive bacteria leukocyte esterase, and nitrites. The liver function tests were also elevated, with an aspartate aminotransferase and alanine aminotransferase in the 300s. His creatinine was 1.6.
Imaging studies included a normal chest x-ray. The patient was given empiric ceftriaxone and saline in the ED and admitted. The patient was cooperative, well-nourished, and in no acute distress. There was no guarding, rebound, or tenderness on the gastrointestinal exam, no mention of flank tenderness, and the rest of the exam was unremarkable.
The principal admitting diagnosis was a urinary tract infection (UTI). The medical team ordered a retroperitoneal ultrasound. A right upper quadrant ultrasound was requested for the elevation of the liver enzymes and viral hepatitis labs. The medical team noted that the patient's baseline creatinine is between 1 and 1.1, currently at 1.6, consistent with an acute kidney injury (AKI). As mentioned above, intravenous (IV) fluid hydration and a renal ultrasound were ordered.
Over the next 24 hours, the creatinine improved to 0.96, the white blood cell count remained normal, and the liver enzymes began trending down. The viral hepatitis studies were nonreactive, and the blood cultures remained negative. The urine culture showed the growth of gram-negative bacteria, speciated as Escherichia coli (E. coli), with sensitivity to fluoroquinolones. The patient was transitioned to ciprofloxacin and transitioned home. Additionally, an echocardiogram was obtained due to left ventricular hypertrophy (LVH) on the electrocardiogram (EKG), which showed normal atrial size, normal ejection fraction, and no regional wall motion abnormalities. The abdominal ultrasound revealed normal-sized kidneys with no hydronephrosis. The right upper quadrant ultrasound showed no evidence of biliary dilation and no sign of cirrhosis. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient level of care.

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

The inpatient admission was not medically necessary. The patient had a UTI, which was appropriately treated with antibiotics and showed improvement, and he was safely discharged home. There is no evidence of a failure of outpatient treatment of cystitis with appropriate antibiotic therapy. There is no indication for inpatient admission due to a lack of severe sepsis, pyelonephritis, or liver pathology warranting an inpatient level of care. The patient was appropriately treated with broad-spectrum antibiotics. The AKI resolved within 24 hours of presentation. A renal ultrasound failed to demonstrate hydronephrosis or pyelonephritis. The mild elevation in the liver enzymes improved, and the liver imaging failed to demonstrate any serious pathology. The inpatient hospitalization exceeded the generally accepted medical practice standards in both duration and extent while producing equivalent therapeutic and diagnostic results.