Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Urinary tract infection/prostatitis.
Treatment:  Inpatient admission.

The insurer denied: Inpatient admission.  The denial is overturned.

The patient is an adult male with no pertinent past medical history. He presented to the Emergency Department (ED) with complaints of fever, dysuria, bilateral flank pain for one day that started the day prior to presentation.  The patient also reported that he had urinary frequency and some lower abdominal pain. The pain was described as six out of ten (6/10) in severity, sudden upon waking up in the morning, and aching in sensation. He had poor PO (oral) intake since symptoms onset and nausea, but he was not vomiting.

The patient was found to have clinical suspicion for UTI (urinary tract infection) / prostatitis and was admitted due to concern for possible sepsis and treated with IV (intravenous) antibiotics and evaluation by infectious disease consult.

The inpatient admission was medically necessary.

The patient is a male with no pertinent past medical history. He presented to the Emergency Department (ED) with complaints of fever, dysuria, bilateral flank pain for one day that started the day prior to presentation. The patient also reported that he had urinary frequency and some lower abdominal pain. The pain was described as 6/10 in severity, sudden upon waking up in the morning and aching in sensation. He has had poor PO (oral) intake since symptoms onset, and nausea, but he was not vomiting.

In the ED (emergency department), the patient's vitals were BP (blood pressure) 170/103, Tmax (max temperature) 100.8, pulse 100. The patient's pain was nine out of ten (9/10). On exam, there was generalized abdominal tenderness. Right and left CVA (costovertebral angle) tenderness was noted. Labs were significant for WBC (white blood count) 16.5, LA (lactic acid) 2.7, Mg (magnesium) 1.5, total bilirubin 3.4, direct bilirubin 1.0. UA (urinalysis) revealed small leukocyte, large blood, protein 100, PO2 (partial pressure of oxygen) 26, lactic acid 2.7; micro: moderate bacteria. Urine and blood cultures were sent. Influenza/RSV (respiratory syncytial virus)/COVID were negative. The patient was treated with Tylenol, IV (intravenous) fluid bolus (normal saline), IV (intravenous) antibiotic - Ceftriaxone 1 g (gram); morphine 4 mg (milligrams) IV (intravenous).

CT (computed tomography) scan abdomen and pelvis showed unremarkable examination of the abdomen and pelvis. The patient was admitted to the inpatient setting for further management for E. coli (Escherichia coli) septicemia, UTI (urinary tract infection)/possible prostatitis.

The patient was found to have bacteremia, and blood culture was reported positive. Blood cultures are growing E. coli (Escherichia coli).

The next day the patient was seen by Infectious Disease. Impression was prostatitis as the source of infection, and the recommendation was to continue Ceftriaxone pending culture results. US (ultrasound) renal including bladder completed showed partly distended urinary bladder and mild prostatic hypertrophy.

The patient's leukocytosis was improving. The E. coli (Escherichia coli) in the blood was resistant to ciprofloxacin. Infectious disease consult recommendation was to continue ceftriaxone and switch to an oral third-generation cephalosporin.
The patient was deemed medically stable and discharged home. 

The patient had presentation consistent with sepsis due to UTI (urinary tract infection)  prostatitis, and treatment in inpatient setting was needed for adequate treatment and monitoring to ensure that the patient was responding well and change treatment as needed. Additionally, the blood culture was not finalized, and inpatient treatment was needed to ensure that the treatment is appropriate according to sensitivities and also to ensure that the blood culture has cleared (negative blood culture).

In view of all of the above considerations, inpatient treatment was medically necessary and appropriate for this patient.