Appeal type: Medical necessity
Decision: Upheld

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


This is a patient with a past medical history significant for bipolar disorder, coronary artery disease and myocardial infarction, status post percutaneous coronary intervention (PCI), thalamic cerebrovascular accident (CVA), type 2 diabetes mellitus with insulin pump complicated by hypoglycemic episodes, and hypothyroidism who presented to the hospital with dysuria and urinary incontinence. It was reported that the patient was previously evaluated at urgent care because of falls. Due to progressive urinary incontinence, the patient started to wear Depends.
Reportedly, the patient underwent transgender surgery which included an orchiectomy, however, the patient did not have any other urogenital surgeries. In the past, the patient was diagnosed with benign prostatic hyperplasia (BPH) and is on Finasteride. At the time of admission, the patient denied a fever but complained of flank pain.
In the emergency department, a urinalysis was performed and reportedly demonstrated pyuria.
A computed tomography (CT) scan of the chest, abdomen, and pelvis without contrast did not show significant abnormalities. A CT scan of the cervical spine did not show an acute fracture or subluxation. A CT scan of the head revealed no acute intracranial abnormalities.
The patient was admitted to the hospital for a fall, pyelonephritis, lower extremity cellulitis, bipolar disorder, status of a transgender person from male to female, also type 2 diabetes mellitus, obstructive sleep apnea, hypothyroidism, and hypertension.
In the hospital, the patient was seen by the urology service who recommended the continuation of treatment with oxybutynin due to urge incontinence. The urine culture demonstrated only mixed microorganisms. During the hospital stay, the patient received Zosyn for 3 days and was discharged home on Ceftin. The patient was recommended to follow up with a urologist as an outpatient.
On the day of discharge, the patient complained of some dizziness, which was thought to be related to benign positional vertigo for which the patient received meclizine. The patient's clinical condition continued to improve. The patient was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
At the time of admission, the patient was afebrile, hemodynamically stable, and had a normal white blood cell count. Since there was a concern for possible acute pyelonephritis, the admission for observation to establish this diagnosis was reasonable. However, the patient remained afebrile and hemodynamically stable. The urine culture came back essentially negative.
Even though the patient's blood sugars were elevated, there was no evidence that the patient had diabetic ketoacidosis, hyperglycemic hyperosmolar state, or hyperglycemia associated with hemodynamic instability, altered mental status, severe or profound dehydration, severe or persistent vomiting, severe electrolyte abnormalities. Furthermore, there was no evidence that the patient's blood glucose levels continued to be too high despite treatment provided during the observation period. 
Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.