Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient has a past medical history significant for suicidal ideation and presented to the emergency department (ED) with a three-day history of acute back and right flank pain. She also experienced some nausea, decreased appetite, and fever to 101.8 degrees Fahrenheit. She reported being sexually active with two partners with inconsistent use of protection. Vital signs included temperature 38.1 degrees Celsius, heart rate 99, respiratory rate 20, and blood pressure 127/70. The examination was significant for moist mucous membranes, a regular heart rate and rhythm, clear lungs, right lower quadrant and left lower quadrant tenderness, right-sided costovertebral angle (CVA) tenderness, no rebound or guarding, no tenderness at McBurney's point and negative Murphy's sign, positive obturator and psoas signs on the right, right adnexal tenderness, no vaginal discharge, normal mood and affect, and non-focal neurologic exam. 

Laboratory evaluation revealed leukocytosis with a white blood cell count (WBC) count of 18.14 thousand (K) and left shift with 80% neutrophils and 7% bands, mild metabolic acidosis with carbon dioxide (CO2) 20, and elevated C-reactive protein (CRP) 55.890. A urinalysis was grossly positive with 15-30 WBCs, 2 plus (+) protein, 2+ blood, and 1+ leukocyte esterase. She was treated with Zofran, Toradol, Tylenol, an intravenous (IV) fluid bolus, and ceftriaxone for presumptive gonorrhea. A surgical consult was obtained to evaluate for appendicitis. A computed tomography (CT) scan of the abdomen and pelvis was significant for right proximal urothelial enhancement and periureteral fat stranding consistent with right-sided acute pyelonephritis. She was given a second higher dose of ceftriaxone for pyelonephritis. A transvaginal ultrasound revealed no evidence of ovarian torsion, but there was a left ovarian hemorrhagic cyst. She was subsequently admitted to the pediatric unit for further management. Over the course of her hospital stay, she had intermittent fevers and abdominal/flank pain treated with Tylenol. She was tolerating a regular diet and maintaining good urine output. She was afebrile for 24 hours. A urine culture was positive for greater than 100K colonies E. coli. She was deemed stable for discharge to complete a course of therapy with Bactrim. At issue is the medical necessity of an inpatient stay. 

An acute inpatient admission was not medically necessary. The patient could have been safely managed at a lower level of care. 

This patient presented with flank pain and abdominal pain, a fever, and decreased appetite. Evaluation in the ED revealed right-sided pyelonephritis for which she was given a dose of ceftriaxone. She was admitted for treatment of pyelonephritis and urosepsis, but was overall hemodynamically stable, with no evidence of significant dehydration, pain that was manageable with enteral medications, and no complicating underlying medical condition. She did not require acute inpatient admission and could have been safely managed at a lower level of care.  

Flank pain historically is associated with renal pathology because of the retroperitoneal placement of the kidneys. Patients may present with flank pain as a result of urinary tract infection/pyelonephritis, trauma, or renal stones. Work-up may include laboratory evaluation, ultrasound, and/or CT scan. Treatment is pathology specific. Acute abdominal pain is a very common complaint in children and adolescents. The differential diagnosis is quite broad, including infectious causes, structural abnormalities, renal causes such as stones, constipation, behavioral/emotional issues, inflammatory diseases, and diseases associated with malabsorption. History, physical examination findings, lab evaluation, and radiographic studies provide additional clues to the etiology. Radiographic studies include plain x-rays, ultrasound, and CT scan with and without contrast. A urinary tract infection can involve the upper tract as pyelonephritis or the lower tract as cystitis, and may involve abdominal pain, flank pain, or both. In the absence of fever, cystitis is most common, particularly in post-pubertal girls. Symptoms of cystitis include dysuria and urinary frequency. Treatment involves a two to four-day course of oral antibiotics effective against Escherichia (E.) coli, the usual culprit. More complicated urinary tract infection may involve systemic symptoms, such as fever, abdominal pain, and vomiting, particularly in infants and young children. In patients that are sexually active, urinary symptoms may be caused by infection with Chlamydia or Gonorrhea and should be considered in the differential diagnosis. Deoxyribonucleic acid (DNA) testing is rapid and reliable. Treatment involves ceftriaxone and either azithromycin or doxycycline. Pelvic inflammatory disease is an infection of the upper genital tract occurring mainly in young sexually active girls. The majority of patients can be treated in the outpatient setting.