Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient Admission.  The denial is upheld. 

The patient is an adult female with a history of anxiety, depression, and migraines. She presented to the ED (emergency department) with complaints of heavy vaginal bleeding after intercourse. Gynecology consult was obtained, and packing was placed. The patient had blood work that revealed mild anemia from 12.8 to 10.3. She was not transfused, as she was hemodynamically stable. She was however found to have a fever to 102. Urinalysis revealed abnormalities. She had a CT (computed tomography) scan and a pelvic ultrasound, which revealed cystitis but no pyelonephritis or pelvic abscess. She had normal blood work except for mild anemia. She had negative blood cultures and negative STD (sexually transmitted disease) panel. She had normal blood gases, normal electrolytes. The patient was admitted for sepsis from a UTI (urinary tract infection). She was given IV (intravenous) fluids, IV (intravenous) ceftriaxone and IV (intravenous) vancomycin. She had stable vital signs. Repeat blood work was normal. 

The inpatient admission was not medically necessary. 

Urinary tract infections (UTIs) include cystitis (infection of the bladder/lower urinary tract) and pyelonephritis (infection of the kidney/upper urinary tract). The pathogenesis of UTI (urinary tract infection) begins with colonization of the vaginal introitus or urethral meatus by uropathogens from the fecal flora, followed by ascension via the urethra into the bladder. Pyelonephritis develops when pathogens ascend to the kidneys via the ureters. Pyelonephritis can also be caused by seeding of the kidneys from bacteremia. It is possible that some cases of pyelonephritis are associated with seeding of the kidneys from bacteria in the lymphatics. 

The decision to admit patients with acute complicated UTI (urinary tract infection) 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] 38.4Celsius/>101Fahrenheit) 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 UTI (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. 

Many patients can be managed in the outpatient setting. As an example, in a study of 44 patients with pyelonephritis but no major comorbidities by Ward, a 12-hour observation period with parenteral antimicrobial therapy in the emergency department followed by completion of outpatient oral antimicrobials was effective management for 97 percent of patients. 

In review of the medical record provided, there is no evidence that the patient had pyelonephritis, bacteremia, or sepsis. She had a fever, but this was not sustained and improved after antibiotics. Her imaging did not reveal a pyelonephritis or abscess. Her blood work did not reveal leukocytosis, electrolyte abnormalities, or acidosis. She was otherwise healthy with no comorbidities. There is no evidence that she required an acute inpatient admission. The same outcome could have been achieved at a lower level of care.