Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Fever, Chills and Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult obese male with history of hypertension, type 2 diabetes mellitus, status post gastric sleeve who presented to emergency department (ED) with complaint of 
suprapubic pain, testicular pain, dysuria, and subjective fever of two days duration. Medications at time of presentation included tadalafil, aspirin, glucotrol, prinivil, glucophage, zocor and 
xalatan. The pain worsened with urination. In the emergency department, the patient was afebrile and hemodynamically stable; his examination was with bilateral testis pain and ultrasound showed no evidence of torsion, testes with good flow. The patient was noted to have urinalysis with greater than (>) 50 white blood cells and large leukocytes, and white blood cell (WBC) count was elevated to 19.9. The patient admitted to inpatient service for hydration, antibiotics (ceftriaxone and doxycycline administered) and further evaluation at urology was recommendation. In the emergency department, the patient's blood pressure was 123/77, temperature was 36.7, pulse oximetry was 98% and pule was 75. A renal/bladder ultrasound was completed that demonstrated no hydronephrosis and a bladder volume of 75 milliliters (mL). On day #2, the patient's pain was 8/10 urethral pain radiating to testes with voiding. He was afebrile, pulse was 60, glucose was 91-152, white blood cell count was 15.5, reports fever as resolved, and creatinine was 1.2. On day #3, the patient's white blood cell count was 9.4, 
glucose was 92, and creatinine was 0.9. Computed tomography (CT) of the abdomen and pelvis was obtained to rule out stones - there were no stones, no hydro, and question of cystitis changes. 
The patient was started on Flomax. Blood and urine cultures had no growth. On day #4, the patient's white blood cell count was 4.2. On day #5, dysuria was better, and the patient was afebrile with a pulse of 59. On day #6, the patient was afebrile and white blood cell count was 5.7. The patient was discharged to home on day #7 with addition of Flomax for urinary symptoms and to continue course of antibiotics on oral Vantin with recommendation for follow up with urology and outpatient Holter monitor.

The requested health service was not medically necessary.

The patient could have been treated at a lower level of care with shorter duration. On presentation, the patient was afebrile, hemodynamically stable, and blood sugars were adequately controlled. He had no history of reduced urine output, no renal disease requiring inpatient care, no severe/persistent dehydration, urologic condition warranting inpatient care such as 
obstruction, gross hematuria, immunocompromised, acute urinary retention, failure of outpatient therapy, or scrotal/testicular condition requiring inpatient care. The patient's risk factor for "complicated UTI" included male sex and diabetes. However, the patient did not have evidence of bladder outlet obstruction or other risk factors and his blood sugars were stable on presentation. Due to the concern for infection, underlying diabetes mellitus, with the elevated white blood cell count and symptoms of pain further evaluation and antibiotic therapy until 
culture results return was warranted but at a lower-level care.