Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who initially presented to the emergency department with back pain. The pertinent history included spine stimulator placement surgery. Additional history included polyneuropathy, myocardial infarction, hyperlipidemia, and hypertension. Initial examination documented left costovertebral tenderness and left upper quadrant tenderness. The surgical site appeared to be healing well. The emergency department physician had concerns for pyelonephritis. The patient was admitted to the hospital and placed on empiric intravenous ceftriaxone. A computed tomography (CT) scan of the abdomen/pelvis revealed perinephric stranding without hydronephrosis. She was afebrile and hemodynamically stable. The WBC was normal. The pain improved. A urine culture grew Escherichia coli. Blood cultures were unremarkable. The treatment plan was unchanged. The bacteria was not resistant to first-line antibiotics. The patient was discharged with oral ciprofloxacin. At issue is the medical necessity of an inpatient admission.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
Colgan et al. noted pyelonephritis 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 degrees Fahrenheit (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 white blood cell casts. Indications for hospitalization include comorbid conditions (e.g. renal dysfunction, urologic disorders, diabetes mellitus, or advanced liver or cardiac disease), hemodynamic instability, male sex, metabolic derangement (e.g. acidosis), pregnancy, severe flank or abdominal pain, inadequate oral intake, and/or very high fever (greater than [>] 103 degrees F).[1]
The patient had no significant genitourinary history and presented with concerns for flank pain and chills. Initial evaluation found the patient to be afebrile, hemodynamically stable, without a leukocytosis, and with pyuria and bacteriuria. CT of the abdomen/pelvis revealed perinephric stranding without abscess or hydronephrosis. The treatment plan included empiric ceftriaxone and supportive care. Following observation care, no complications had arisen, oral intake was tolerated, and blood cultures were negative. Ultimately the urine culture grew a sensitive Escherichia coli and the patient was discharged on first-line oral antibiotics. No other issues or complications were documented.
The clinical indications for admission to inpatient care were not met. The patient had urinary symptoms, but did not have evidence of systemic infection or end organ compromise. Observation was indicated due to continued pain and a pending urine culture.[2]