Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyelonephritis, Sepsis, Abdominal Pain, Fever
Treatment: Inpatient Hospital
The insurer denied the hospital stay.
The health plan's determination is overturned.

This patient is a female who was admitted to the hospital with back pain radiating to the left side of the abdomen and left flank for two days. She denied dysuria, fever, or hematuria. She had a maximum temperature of 102.9 degrees Fahrenheit, a heart rate of 100, her respirations were 20, and her blood pressure was 105/64. The examination showed an oriented person with a normal cardiopulmonary exam. She had left costovertebral angle (CVA) tenderness which was noted without evidence of right CVA tenderness. There was no rebound or guarding on the abdominal examination. Her laboratory studies showed significant leukocytosis of 27 and a hemoglobin of 13.1. Her electrolytes appeared stable. Her creatinine was 0.87, her liver function tests (LFT's) were unremarkable and her lactic acid was 1.8. The patient's urinalysis was significant for nitrites, leukocyte Estrace, and 248 white blood cells. Her chest x-ray was negative for pulmonary disease. The computed tomography (CT) of the abdomen showed a large uterine fibroid at 3.7 centimeters (cm), a normal colon and appendix, and no hydronephrosis or hydroureter. The bladder was partially distended.

The medical team admitted the patient for sepsis due to pyelonephritis and urinary tract infection. Broad-spectrum intravenous (IV) antibiotics were initiated, and urology and infectious disease were consulted to evaluate.

Neurology assessed the patient and requested a catheterized urinalysis and continuation of Zosyn. The infectious disease specialist recommended IV Rocephin instead and awaiting the culture results.

The health plan in its determination of medical necessity, did not act reasonably, with sound medical judgment, nor in the patient's best interest. Based on the provided documentation, an inpatient hospitalization is indicated for this patient.

The inpatient hospital admission was medically necessary. Based on the provided documentation, the patient has sepsis caused by a urinary tract infection, with fever, tachycardia, borderline hypotension, lactic acidosis, and transient hypoxemia. The medical team documents no pyelonephritis on the CT scan or hydronephrosis and continued treatment with Rocephin. Later that day, the patient developed an acute onset of hypoxia, with rigors and left arm pain. Oxygen was applied by nasal cannula, a stat chest x-ray was obtained, and the sepsis protocol was reinitiated. Repeat blood cultures were obtained as well. The x-ray showed the development of interstitial fluid and pulmonary vascular congestion. The repeat lactic acid was 2.4, however, several hours later, it normalized to 0.9. The patient was eventually weaned off the oxygen. The patient's blood cultures remained negative over the next 48 hours. The patient was transitioned to Vantin. 

Treatment of severe sepsis is performed under an inpatient level of care. The patient was on appropriate antibiotic therapy, and 24 hours into the hospital stay, she remained febrile, tachycardic, and had a worsening lactic acidosis. Based on medical necessity, inpatient criteria are satisfied.