Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain; fever 
Treatment: Inpatient admission 

The inpatient admission was medically necessary.

The patient is a female child. She has a medical history significant for asthma. She presented to the ED with three-day history of diffuse lower quadrant abdominal pain worse on the right, one-day history of fever, and slight cough. She had a similar episode two months earlier, presented to the ED and had a full work-up including CT and ultrasound, eventually attributed to possible inflamed bowel. She was seen by the pediatrician the day prior to this presentation where urine was reported as negative per the mother. 

The patient's vital signs included temperature 38.5, heart rate 134, respiratory rate 22 with 98% saturation in room air, and blood pressure 98/68. Right lower quadrant pain was rated 5/10. Examination in the ED was significant for right lower quadrant pain with no rebound. The remainder of the exam was "normal." Laboratory evaluation was significant for mild hyponatremia, mild metabolic acidosis, mild hyperglycemia, normal WBC (white blood cell) count with borderline left shift, normal coagulation, negative rapid strep testing, and urinalysis with moderate leukocyte esterase and negative nitrite. Abdominal x-ray noted only paucity of small bowel gas. She was then transferred to SNCH for further evaluation with ultrasound and CT scan. 

The patient's ultrasound failed to visualize the appendix. CT scan revealed bilateral right greater than left pyelonephritis and thickening of the urinary bladder compatible with cystitis. She was treated with ceftriaxone and acetaminophen and admitted for further management. More detailed examination following admission included no acute distress, tachycardia, clear lungs, benign abdomen, and non-focal neurologic exam. Admission orders included IV fluids, acetaminophen as needed, and ceftriaxone. 

The following day, the patient had improved. She had no fevers since the day before, with maximum 101.2. Vital signs were stable and age appropriate. She was eating and drinking well, with no gastrointestinal symptoms and no signs of dehydration. She was back to her baseline. Urine culture was positive for 70K gram negative rods, later identified as E. coli. Blood culture was negative. She remained on IV fluids at a decreased rate. Later in the day, she was deemed stable for discharge home, to continue a course of therapy with Augmentin. 

Urinary tract infection (UTI) can involve the upper tract as pyelonephritis or the lower tract as cystitis. 

This young female child presented to the ED with abdominal pain initially concerning for appendicitis. She had been to the ED two months prior with similar pain, with comprehensive work-up that was negative. She had also been to the primary care provider the day before and urine testing was negative. Upon presentation this time, she was febrile, with persistent tachycardia despite defervescence, and studies indicative of bilateral pyelonephritis with cystitis. While she was hemodynamically stable, with no significant dehydration, and no further significant pain, she had a complicated urinary tract infection with tachycardia, concerning for evolving infection and possible sepsis. She had failed evaluation in the outpatient setting, and remained symptomatic despite prolonged monitoring and intervention in the ED. Based on the medical record, current standards of care, and the related literature, acute inpatient admission was medically necessary and appropriate.