Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; urinary tract infection.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is a toddler female child that presented to the ED (emergency department) with six-day history of fevers to 105. The patient was taken to an emergency department five days prior to this presentation for evaluation. At that time, respiratory viral panel was negative as was chest x-ray. The patient continued to have low-grade fevers to 100.7 and was taken to the pediatrician one day prior to this presentation. Rapid COVID and respiratory viral panels were obtained, and the patient was discharged home with instructions to the parents to go to the emergency department for persistent fevers. The patient also had three-day history of cough, some runny nose and congestion, diarrhea, decreased feeding, and fatigue. The patient's vital signs included temperature 39.8, heart rate 188, and respiratory rate 38. 
Examination was significant for no acute distress, moist mucous membranes, tachycardia, clear lungs, benign abdomen, no rashes, prolonged capillary refill more than three seconds, and nonfecal neurologic exam. Test results from the pediatrician's office returned positive for COVID. Both mom and baby had COVID diagnosis three weeks prior. Laboratory testing revealed white blood cell (WBC) count 17.8 thousand (K), platelets 478 thousand, C-reactive protein (CRP) 129.7, erythrocyte sedimentation rate (ESR) 78, sodium 132, bicarb 21, and COVID positive. Urinalysis was positive for white blood cells 543, red blood cells 16, white blood cell clumps 4+, bacteria 2+, and leukocyte esterase 3+. Renal ultrasound was unremarkable, decreasing concern for pyelonephritis. The patient was treated with Tylenol and ceftriaxone and was admitted for further management of sepsis secondary to urinary tract infection. 
Admission orders included intravenous fluids, ceftriaxone, pending blood and urine cultures, regular diet for age, and vital signs every four hours. The patient was changed to cefazolin the following day with consideration for transition to oral antibiotics if she was afebrile. The patient did well overnight, with improving intake and had no fevers. Urine culture returned positive for Escherichia coli (E. coli). The patient was deemed stable for discharge home on oral antibiotics.

The proposed inpatient hospital admission was not medically necessary.

Acute inpatient admission was not medically necessary. This young female infant presented to the emergency department with high fevers, decreased intake, and fussiness. She had recently been diagnosed with COVID and had some lingering dry cough. Urinalysis was grossly positive in the emergency department and culture subsequently returned positive for Escherichia coli. Renal ultrasound was unremarkable. While it was reasonable and appropriate to monitor this child in the hospital while treating with antibiotics pending culture results, the infant was overall hemodynamically stable with no significant underlying medical issues and no significant metabolic abnormalities. She did not require acute inpatient admission and could have been safely managed at lower level of care.