Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Urinary Tract Infection, abdominal pain.
Treatment:  Inpatient hospitalization.
The insurer denied the inpatient hospitalization.  The denial is overturned.

The patient is an adult female whose inpatient hospital admission is under review. The patient presented to the emergency room with three days of left-sided abdominal pain. She also had chills, nausea, dysuria, urinary frequency and foul-smelling urine. She was treated as an outpatient with ampicillin (ten days) and nitrofurantoin (three days) without improvement. She had a past medical history of frequent urinary tract infections, gastroesophageal reflux disease, obesity, tubal ligation, dilatation and curettage, gastrectomy, anemia, and depression.

In the emergency room, the patient's assessment revealed the following:  Temperature - 98.8; Pulse - 99; Blood pressure -133/78; Respiratory rate - 24; General: no appreciable disease; Chest: normal; Cardiovascular system: normal; Abdomen: normal bowel sounds, positive tenderness, left lower quadrant greater than left upper quadrant, and no rebound or guarding.

The patient's lab values were as follows: sodium (Na) - 138, potassium (K) - 3.3 (low), chloride (Cl) - 110, carbon dioxide (CO2) - 24, blood urea nitrogen (BUN) -15 , creatinine (Cr) - 0.79, lactate - 1.6, white blood cells (WBC) - 7.97, hemoglobin (Hg) - 6.9, hematocrit (Hct) - 26.5, and platelets (Plt) - 305.  Her urine analysis (UA) showed moderate epithelial cells; it was positive for nitrates and negative for leukocyte esterase.  The patient's urine culture grew Escherichia coli (E.coli).  Her blood culture was negative.  The patient had a computed tomography of the abdomen and pelvis which showed no nephrolithiasis, hydronephrosis; small left ovarian corpus luteum; and small enhancing lesion left uterine wall.

In the emergency room, the patient was thought to have a urinary tract infection failing outpatient therapy, possible pyelonephritis, and anemia (possibly gastrointestinal bleed). She was hospitalized and started on intravenous cefazolin, and received blood transfusions. In the hospital, the patient was changed to intravenous ceftriaxone, improved and was discharged home on oral antibiotics.

The proposed inpatient admission was medically necessary.

The treatment is medically necessary for several reasons. The Infectious Diseases Society of America has guidelines for treating simple uncomplicated urinary tract infections with oral antibiotics as an outpatient (1). This patient does not represent a typical such patient.  This patient has failed two outpatient treatments already. When she presented to the hospital she had abdominal pain that was worsening, another concerning sign that the treatment was not working. Standard of care would require admission and intravenous treatment of such a patient, especially if there was suspicion of pyelonephritis, as in this case. Furthermore, the patient had anemia, which had the potential to complicate the course. For example, if she progressed to urosepsis, then the anemia would make it more likely she would have hypotension and shock. For these reasons, the decision to admit and treat with intravenous medications was medically necessary.