Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history significant for benign prostatic hyperplasia (BPH), nephrolithiasis, and hemorrhoids who presented to the emergency department with complaints of difficulties in urination and pain associated with urination in the suprapubic region.
Reportedly, the patient saw a urologist approximately 1 week before the day of admission and underwent a cystoscopy. Following the procedure, the patient was told that his prostate was severely enlarged. He was started on Flomax. Three days later he started to experience fever, difficulties urinating, and pain associated with urination.
Upon initial evaluation in emergency department, the patient was found to have a temperature of 100.7 degrees Fahrenheit (F), heart rate 99 beats per minute (bpm), respiratory rate 18, blood pressure 106/65, and oxygen saturation 100% on room air.
The patient was not in acute distress. His head, eyes, ears, neck, throat (HEENT) exam was within normal limits. The cardiovascular exam was unremarkable. Lungs were clear to auscultation. The patient had suprapubic tenderness as well as mild costovertebral angle (CVA) tenderness. The rest of the physical exam was unremarkable.
Laboratory evaluation revealed that the patient's white blood cell count was 21,000, hemoglobin 14.3, hematocrit 42.6, and platelets 186. Sodium was 133, potassium 3.3, chloride 100, bicarbonate 21, blood urea nitrogen (BUN) 9.0, creatinine 0.8, and glucose 117. Liver function tests were within normal limits.
A urinalysis was positive for white blood cells and red blood cells. It also had a trace of leukocyte esterase.
The patient was admitted to the hospital with a diagnosis of urinary tract infection, pyelonephritis. He underwent the insertion of a Foley catheter and received treatment with intravenous fluids and antibiotics. Blood and urine cultures were sent.
The health plan's determination is overturned.
The requested health service/treatment of inpatient hospital stay was medically necessary for this patient at an acute inpatient level of care to provide treatment with intravenous fluids and intravenous antibiotics, to ensure hemodynamic stability, and to follow up on the blood and urine culture results. There was a very high probability that the patient had sepsis. This kind of care is usually provided in inpatient settings.
At the time of admission, the patient met sepsis criteria since he had 3 positive systemic inflammatory response syndrome (SIRS) criteria and clinical evidence of a urinary tract infection. The SIRS criteria are temperature greater than 100.4 F, heart rate greater than 90 bpm, white blood cell count greater than 12,000/mm3 [cubic millimeter].
Based on the recent history of a cystoscopy, presence of dysuria, urinary retention, and flank discomfort, there was a high probability that the patient had a urinary tract infection and sepsis due to the urinary origin. Sepsis is a dangerous medical condition, especially when it remains inadequately treated. Inadequately treated sepsis is associated with a high mortality rate.
Therefore, taking into consideration all of the circumstances, the admission to the hospital for administration of intravenous fluids, antibiotics, and close monitoring was essential. In order to provide the evaluation and treatment in a timely manner, admission at the acute inpatient level of care was appropriate.