Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Infection. 
Treatment: Inpatient admission. 
The health plan denied the inpatient admission. 
The determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for fever and flank pain. She has no significant medical history. Her initial vital signs revealed a temperature of 102 Fahrenheit (F), a heart rate of 126 beats per minute, a blood pressure of 119/63 millimeters of mercury, a respiratory rate of 17/minute, and a peripheral capillary oxygen saturation (SpO2) of 99 percent (%). Initial examination documented the patient as alert and oriented with left flank tenderness. Initial laboratory testing revealed a white blood cell (WBC) count of 11.3, a hemoglobin of 12.4, a platelet count of 222, a sodium of 140, a potassium of 3.6, a blood urea nitrogen (BUN) of 11, a creatinine of 0.78, a glucose of 97, and a lactic acid of 1.2. A computed tomography (CT) scan of the abdomen/pelvis revealed findings suggestive of a right pyelonephritis without complication. Fluid resuscitation with 3 liters (L) and empiric antibiotics were administered. Overnight she had a temperature of 102.9 F. Her tachycardia improved, and the WBC count normalized. Oral medications were tolerated. Intravenous (IV) fluids and antibiotics were continued. The next day, she was afebrile and hemodynamically stable, with no new issues. The patient was discharged with oral cephalexin. At issue is the medical necessity of the inpatient emergency admission. 
The health plan's determination of medical necessity is upheld in whole. 
The requested health service/treatment of inpatient emergency admission is not medically necessary for this patient. 
Colgan et al. listed criteria for the diagnosis of pyelonephritis. This includes a history of urinary frequency, dysuria, flank pain, fever, chills, nausea, and/or vomiting. Concerning physical examination, findings include a temperature greater than 100.4 F, tachycardia, costovertebral tenderness, and suprapubic tenderness. Concerning laboratory findings include leukocytosis and a urinalysis showing positive leukocyte esterase test, microscopic pyuria or hematuria, or WBC casts. Furthermore, indications for hospitalization include comorbid conditions, hemodynamic instability, male sex, metabolic derangement, pregnancy, severe flank or abdominal pain, inadequate oral intake, and/or very high fever (greater than 103 F).[1] 
The patient had no past medical history or co-morbidities and presented with dysuria, flank pain, and fever. Initial evaluation revealed a temperature of 102 F, tachycardia, and leukocytosis. CT findings were consistent with pyelonephritis. The treatment plan included IV fluids and empiric antibiotics. Following initial care, the patient was afebrile, hemodynamically stable, and tolerating oral intake. No other issues or complications were documented. 
Moreover, clinical indications for admission to inpatient care were not met. There was no documented hemodynamic instability, severe or persistent altered mental status, persistent of worsening of clinical finding initial care, pregnancy, kidney transplant recipient with suspected pyelonephritis, significant uropathy, suspected infection of an indwelling prosthetic device, stent, implant, graft, ureteral obstruction, bladder emptying significantly impaired, renal or perinephric abscess, emphysematous pyelonephritis or cystitis, pyonephrosis, acute renal failure, or need for intravenous hydration support despite initial care.[2]