Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Pyelonephritis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This child presented to the emergency department with a 2-day history of fever associated with headache, dysuria, and abdominal pain. The patient's maximum temperature prior to arrival was 102 Fahrenheit (F). The patient was given Motrin that morning. Vital signs documented heart rate of 143 bpm (beats per minute) and temperature of 103 F. Assessment was pyelonephritis and the patient was recommended for labs and admission for intravenous (IV) antibiotics. It was noted that urinalysis was positive and white count was 20.8. The patient received 1 dose of ceftriaxone in the emergency department. History and physical reported patient had a history of urinary tract infection a few months ago that was treated with a 5-day course of oral antibiotics. The patient had complaints of fever, dysuria, and abdominal pain for 2 days. The patient was recommended for continued IV antibiotics while pending culture and sensitivity. On the basis of history and laboratory findings, the patient was being treated for sepsis due to acute pyelonephritis. Progress note reported the patient was feeling better but had no appetite. The patient was afebrile overnight and denied abdominal pain or dysuria. The patient had not had a bowel movement. MiraLAX was started due to constipation. Blood and urine cultures were pending. Treatment plan was for continued admission for IV antibiotics. Diagnoses included urinary tract infection and pyelonephritis. Progress note stated the patient was afebrile overnight and had a bowel movement that morning. The patient complained of no abdominal pain or dysuria. Blood cultures were negative at 24 hours and urine culture was still pending. The patient was clinically improving but required continued admission pending urine culture sensitivity. Discharge diagnoses included pyelonephritis ruled out, sepsis ruled out, constipation, and unspecified fever. The patient was febrile twice during the hospital course which resolved with Tylenol. It was noted that the patient continued to improve and after 2 days she no longer complained of abdominal pain or dysuria. It was noted that urine cultures came back with no growth after 48 hours. IV antibiotics were discontinued, and the patient was discharged home with follow-up with primary care provider (PCP) in 1 week. 

The inpatient admission is considered medically necessary for this patient. The patient presented to the emergency department with fever and elevated heart rate. There were complaints of headache, dysuria, and abdominal pain. The patient had a history of urinary tract infection a few months ago that was treated with a 5-day course of oral antibiotics. The patient received 1 dose of ceftriaxone in the emergency department. The patient required inpatient monitoring due to systemic inflammatory response syndrome (SIRS) status and physician judgment. Per cited references, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation. The entire clinical picture is required to determine resuscitation needs in pediatrics. 

Based on the above, the insurer's denial must be overturned. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the inpatient admission services is substantiated.