Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Stay. 
The denial was: Upheld in whole. 

The patient is a  G10P7027 female who presented to the emergency department with complaints of right sided back pain and hematuria at 14 3/7 weeks gestation. The patient was noted to have seven prior term deliveries and two prior miscarriages. She had no medical or surgical history. There were no medications or allergies reported. She was a non-smoker.

The patient had mild right back pain and hematuria for the several days prior to admission. She had been given a prescription of Macrobid for probably urinary tract infection (UTI) but was recommended to come to the hospital if the hematuria did not resolve. She reported no fever or chills and reported the back pain to be mild. The patient reported mild dysuria that had improved on the day of presentation. She had no nausea or vomiting. She had been able to tolerate a regular diet without any issues. She was afebrile with a normal hemoglobin and hematocrit. She had a normal white count and normal creatinine. The review of systems was noted for hematuria, back pain, and dysuria. The exam was noted to be normal. The patient had stable exam and vitals. She was admitted for urinary tract infection vs. pyelonephritis with hematuria. She was managed on 1 gram of Rocephin daily and urinary culture was completed. There was no acute intervention required at that time. The patient was seen by infectious disease for consultation. There were no changes in plan or new recommendations. The patient continued to have normal vital signs and remained afebrile. The patient had stable and normal vital signs and was improving. She remained afebrile. She had no physical exam findings suggestive of pyelonephritis. Hematuria was improved. Continued monitoring was planned. There were no signs of urosepsis. The patient again had no complaints. She had no pain, nausea or vomiting. She was afebrile with stable vital signs. There was no pain in the flank. She was deemed stable for discharge at that time and plan was made for outpatient follow-up.

The health plan's determination of medical necessity is upheld in whole. 

The inpatient stay was not medically necessary in this case. In this case, the patient had a urinary tract infection and was treated with intravenous (IV) Rocephin. She had hematuria. There were stable vital signs and no evidence of urosepsis. She had no fever. She was stable. She had failed a trial of outpatient oral Macrobid and would have been a candidate for administration of IV Rocephin at a lower level of care status, she did not require an inpatient stay. She was able to tolerate a regular diet. She had no nausea or vomiting that precluded regular diet.

In this case, the services provided could have been provided at a lower level status. There were interventions of IV fluids, Ceftriaxone antimicrobial therapy and teaching that can be provided at a lower level of care in a patient with stable vital signs and absent signs of sepsis or renal failure. There was no evidence that the patient was unstable or requiring of acute inpatient level of care. The imaging by ultrasound and labs for pregnancy could also be performed at a lower level of care.