Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is Upheld.

The patient is an adult female who presented to the emergency department (ED) with abdominal pain six out of ten (6/10). She was found to be febrile to 102. Her respiratory rate was 18, blood pressure (BP) was 137/101, and oxygen (O2) was 98% (percent). She had blood work, urinalysis, x-ray, computed tomography (CT) scan, and pelvic ultrasound. This revealed leukocytosis, urinary tract infection (UTI), and liver steatosis. The patient had a gynecology (GYN) consult. She was given intravenous (IV) fluids, Toradol, acetaminophen, fentanyl, and was started on ceftriaxone. She was also given heparin. On day #3 the gonorrhea and chlamydia (GC/CH) cultures returned positive and intravenous doxycycline was added. She improved and was discharged home with a course of oral doxycycline. The inpatient admission was denied as not medically necessary. This is being appealed.

The proposed treatment was not medically necessary.

The decision to admit patients with acute complicated urinary tract infection (UTI) should be individualized. The decision to admit is usually clear when patients are septic or otherwise critically ill. Otherwise, general indications for inpatient management include persistently high fever (e.g., greater than 38.4 degrees Celsius or greater than 101 degrees Fahrenheit) or pain, marked debility, or inability to maintain oral hydration or take oral medications. Additionally, inpatient management is warranted when urinary tract obstruction is suspected or there are concerns regarding patient adherence. Outpatient management is acceptable for patients with acute complicated urinary tract infection of mild to moderate severity who can be stabilized, if necessary, with rehydration and antimicrobials in an outpatient facility or the emergency department and discharged on oral antimicrobials with close follow-up. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of two points or more, which is associated with an in-hospital mortality greater than ten percent. This is based on assessment of respiration and the partial pressure of oxygen (PaO2), coagulation (platelet count), liver (bilirubin), cardiovascular (mean arterial pressure [MAP]), central nervous system (Glasgow coma scale), and renal function (creatinine and urine output). Termed qSOFA (for quick Sequential Organ Failure Assessment [SOFA]) and incorporating altered mentation, systolic blood pressure of 100 millimeters of mercury (mmHg) or less, and respiratory rate of 22 per minute or greater, provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes.
Quick Sequential Organ Failure Assessment (Quick SOFA) Criteria:
1)Respiratory rate greater than or equal to 22 per minute
2)Altered mentation
3) Systolic blood pressure <= (less than or equal to) 100 millimeters of mercury.

In review of the medical record, this patient was diagnosed with sepsis secondary to a urinary tract infection. However, in review of the definition of sepsis, the patient did not have elevated respiratory rate (18), altered mentation or systolic blood pressure less than 100. She had normal platelets, normal creatinine, normal urine output. There is also not an elevation in the Glasgow coma scale. She did not have a sustained high fever or inability for oral intake. The literature supports that in the absence of sepsis, there is evidence for treatment of pyelonephritis in the emergency room setting or outpatient. The information provided does not indicate that the patient required an inpatient level of care.