Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Urinary Tract Infection
Treatment: Inpatient Hospital Stay.  
The insurer denied the Inpatient Hospital Stay.  The denial was upheld. 

This is a patient who presented to the hospital with complaints of a fever, chills, and epigastric abdominal pain.  Reportedly, the patient was diagnosed with a urinary tract infection several days prior to admission.  The urinary tract infection was treated with Nitrofurantoin with no relief of symptoms.

On the physical exam, the patient's temperature was 99.7 degrees Fahrenheit, blood pressure 115/58, pulse rate 78, respiratory rate 18, and oxygen saturation 93% on room air.  The patient was in no acute distress, head, eyes, ears, neck, throat (HEENT) exam was within normal limits.  Lungs were clear to auscultation.  The heart exam was unremarkable.  The abdominal exam was within normal limits.  The rest of the physical exam was unremarkable.  Laboratory evaluation revealed that her white blood cell count was 22.3, hemoglobin 12.5, hematocrit 38.1, and platelets 522.  Sodium was 135, potassium 3.8, chloride 102, bicarbonate 21, blood urea nitrogen (BUN) 12, creatinine 1.29, and glucose 145.  Alkaline phosphatase was 408, alanine aminotransferase (ALT) 67.  A chest x-ray was interpreted as an unremarkable study.

The patient was admitted to the hospital with leukocytosis and a fever.  She was diagnosed with probable sepsis due to a urinary tract infection.  The patient received treatment with intravenous Ceftriaxone and intravenous fluids.

In the hospital, the patient was seen by an infectious disease specialist who diagnosed the patient with acute cystitis and sepsis. The infectious disease specialist suggested that the urinary tract infection was caused by Escherichia coli. The urinary tract infection led to bacteremia.

The infectious disease specialist recommended to continue treatment with Ceftriaxone intravenously and to subsequently switch the patient to an oral antibiotic when the results of the blood cultures became available.

As a result of the treatment, the patient's clinical condition significantly improved, including the resolution of her symptoms.

Subsequently, the patient was discharged home with recommendations to take oral antibiotics.  At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary. Even though the patient presented with symptoms that included a fever, chills, and recent history of urinary tract infection, the patient did not meet systemic inflammatory response syndrome (SIRS) criteria for sepsis.  During the hospital stay, this patient remained hemodynamically stable.  The symptoms resolved fairly quickly.  Even though the patient had Escherichia coli bacteremia, this did not lead to sepsis syndrome clinically.

The patient had no clinical signs of pyelonephritis since the review of systems was negative for dysuria, hematuria.  There was no costovertebral angle (CVA) tenderness on exam.

According to the notes, the patient's clinical condition significantly improved in the first 24 hours after admission.  On the next day, the patient was afebrile, and the fatigue and suprapubic abdominal pain, epigastric pain, and anorexia completely resolved.

Taking into consideration all of this information, the severity of the patient's condition did not justify admission at the acute inpatient level of care.

Even though the patient had a urinary tract infection and bacteremia, her fever resolved quickly.  There was no mention of hemodynamic instability.  The urinary tract infection was not associated with acute kidney failure or acute electrolyte abnormalities.  There was no mention that the patient was immunocompromised.