Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder/Urinary Tract Infection/UTI.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who initially presented to the emergency department with concerns of fever, chills, and right flank pain. Pertinent history included a diagnosis of a urinary tract infection, sensitive to Cephalosporins; about two-three weeks prior to presentation she was treated with a course of oral antibiotics. Additional history included rheumatoid arthritis. Initial vital signs revealed a temperature of 103F (Fahrenheit), a heart rate (HR) of 134 beats per minute (bpm), a blood pressure (BP) of 92/49 millimeters of mercury (mmHg), a respiratory rate (RR) of 18/minute, and a peripheral capillary oxygen saturation (SpO2) of 97% (percent) on room air. Initial examination documented the patient as alert, oriented, and with costovertebral tenderness. Initial laboratory testing revealed a white blood cell count (WBC) of 10.1, a hemoglobin of 10.1, platelets of264, a blood urea nitrogen (BUN) of 10, a creatinine of 0.7, a sodium of 137, a potassium of 3.6, a carbon dioxide (CO2) of 21.8, a Glucose of 108, and a lactate of 0.92. A urinalysis revealed pyuria and bacteriuria. A computed tomography (CT) of the abdomen/pelvis revealed a new focus of low-attenuation in the right upper renal pole which may be secondary to pyelonephritis and/or small abscess. The patient was admitted to the hospital thereafter. The treatment plan included intravenous fluids, cultures, empiric antibiotics, and consultations. The patient was afebrile and hemodynamically stable. The patient stated she felt better and that the right flank pain had subsided. An infectious disease consultation was obtained whom had an impression of acute right pyelonephritis possible renal abscess. Recommendations were to switch to Levofloxacin for 14 days if discharged and a repeat CT after treatment is completed. A urology consultation was obtained whom had an impression of ascending pyelonephritis. Recommendations were for empiric antibiotics without surgical intervention. The patient was discharged.

At issue is the medical necessity for the inpatient stay.
The health plan's determination of medical necessity is upheld, in whole.

No. Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission.
Colgan et al. listed criteria for the diagnosis of pyelonephritis. This includes a history of urinary frequency, dysuria, flank pain, fever, chills, nausea, and/or vomiting. Concerning physical examination findings include a temperature greater than 100.4F., tachycardia, costovertebral tenderness and suprapubic tenderness. Concerning laboratory findings include leukocytosis and a urinalysis showing positive leukocyte esterase test, microscopic pyuria or hematuria, or white blood cells casts. Furthermore, indications for hospitalization include comorbid conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, or advanced liver or cardiac disease), hemodynamic instability, male sex, metabolic derangement (e.g., acidosis), pregnancy, severe flank or abdominal pain, and/or inadequate oral intake.[1]
In this particular situation, the patient presented with a fever of 103F., tachycardia, chills, and right flank pain secondary to acute pyelonephritis. The attending physician documented that the patient did not complete the appropriate oral course for her previous urinary tract infection that was sensitive to Cephalosporins. The treatment plan included intravenous fluids and empiric antibiotics. Infectious disease recommended transitioning to oral Levofloxacin and urology did not recommend intervention. Following observation care, the patient was afebrile, hemodynamically stable, and presenting symptoms had essentially resolved. No other issues or complications were documented.