Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection.
Treatment: Inpatient Stay.
The insurer denied the Inpatient Stay.
The determination is upheld.

The patient was referred to the emergency department (ED) by her pediatrician with a five-day history of high spiking fevers to 104.9 degrees Fahrenheit. She was initially diagnosed with a viral respiratory infection, with negative rapid strep testing in the office and recommendations for supportive care. She had intermittent vomiting but no diarrhea. In the ED, she was afebrile with an unremarkable physical examination. Laboratory testing was significant for leukocytosis (white blood cell count (WBC) 19.1 thousand [K]), thrombocytosis (platelets 549 K), elevated C-reactive protein (CRP) 13.1, unremarkable metabolic panel, negative expanded respiratory panel, negative coronavirus disease (COVID) polymerase chain reaction (PCR), and urinalysis with large leukocyte esterase and 21 WBCs. A chest x-ray was unremarkable. Cultures were sent. The differential diagnosis included viral respiratory infection, urinary tract infection, bacteremia, viral gastroenteritis, and food poisoning. She was admitted for evaluation and management of a prolonged fever without obvious focus. Admission orders included regular diet for age, intravenous (IV) fluids at maintenance, anti-pyretics as needed, ceftriaxone pending culture results, follow cultures (blood, urine, throat), and renal ultrasound if urinary tract infection confirmed. Overnight, she was febrile to 103 degrees. She was tolerating her diet but had not had a stool for two days, prompting treatment with a glycerin suppository. Cultures remained pending. She had been afebrile for 24 hours and was eating at baseline, passing stool after the suppository. Blood culture was negative pending the final report. A urine culture was positive for Escherichia (E) coli, prompting a renal ultrasound that was normal. She was deemed stable for discharge, to complete seven days of cefdinir.
At issue is the medical necessity of an inpatient stay.

An acute inpatient stay was not medically necessary for the dates in question. The patient could have been safely managed at a lower level of care.
This female developed a high fever with a few episodes of vomiting over the course of five days. She was referred to the ED for evaluation of persistent fevers, with initial work-up suspicious for acute infection (leukocytosis, elevated CRP) and specifically a urinary tract infection (leukocyte esterase, pyuria). She was treated with parenteral antibiotics pending culture results, with an eventual urine culture positive for E. coli. A renal ultrasound was unremarkable. She was discharged to complete a course of enteral antibiotics.
Urinary tract infection (UTI) is a common diagnosis in infants, children, and adolescents. Pathogenesis is multifactorial, and may result from dysfunctional voiding (eg constipation, neurogenic bladder, irritation from bubble baths), instrumentation (eg Foley catheter placement), turbulent flow from voiding abnormalities (eg hydronephrosis, vesicoureteral reflux), or hematogenous spread (eg neonates and young infants). During the first year of life, UTI is more common in uncircumcised boys than circumcised boys. The most common organism is E. coli(Escherichia coli), although viruses and other bacteria may also be responsible for UTI. Presentation of infection varies by age and degree of infection. In young infants, presentation may include fever, lethargy, irritability, and poor feeding. Vomiting and diarrhea may also occur. After the age of two years, cystitis typically presents with low grade fever, dysuria, frequency, abdominal pain, and malodorous urine. Enuresis may also occur in previously continent children. Pyelonephritis may present with high fever, back or flank pain, and fatigue, in addition to urinary symptoms. Sexually active patients may have symptoms associated with sexually transmitted disease. Examination may reveal ill appearance, costovertebral angle tenderness, and abdominal tenderness. A urinalysis may reveal pyuria, bacteriuria, nitrites, leukocyte esterase, and hematuria.  Additional lab studies should also be considered depending on clinical presentation. For neonates and young infants, hospitalization for treatment with parenteral antibiotics is necessary. Older patients that appear ill or dehydrated, or in whom there is possibility of urosepsis or underlying disease also require hospitalization. Older children can typically be treated with enteral antibiotics, with duration of therapy dependent upon age and extent of infection (cystitis versus pyelonephritis). Imaging studies are not routinely necessary. However, for infants and young children with first febrile UTI, renal ultrasound is recommended to identify potential pathology. Voiding cystourethrography is indicated in second febrile UTI to rule out reflux, unless history warrants earlier studies.
While it was not unreasonable to monitor her in the hospital on parenteral antibiotics pending culture results because of the duration and intensity of her fevers, she was overall hemodynamically stable, with no evidence of impending sepsis, no evidence of dehydration, and no concerning underlying medical conditions, she did not require acute inpatient admission and could have been safely managed at a lower level of care.