Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection, Pregnancy.
Treatment: Inpatient Hospital Stay.

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

The patient is a gravida (G) 1 para (P) 0 who had a complaint of back pain and possible pyelonephritis. She had prenatal care that was uncomplicated. She had no symptoms of coronavirus disease (COVID). She was noted to have back pain with positive nitrates on a urinalysis from urgent care. She had stable vital signs and was afebrile. The fetal status was reassuring. She was planned for intravenous (IV) hydration, a renal and bladder ultrasound and repeat urinalysis with complete blood count. This was her first pregnancy. She had a remote history of genital herpes and a prior Bartholin gland excision on the left side. At presentation, her vital signs were stable with a temperature of 100.7 degrees Fahrenheit (F). She had a normal blood pressure of 116/63 and a heart rate of 111. She had a pain score of 6/10. She was noted to have a gravid uterus with no tenderness. Her body mass index (BMI) was 21.79 kilograms per square meter (kg/m2). The exam was otherwise normal. The patient had a white blood cell count of 15.6 with a hemoglobin of 11.1 grams per deciliter (g/dL). She was admitted to labor and delivery (L&D) for treatment of pyelonephritis and Maternal Fetal Medicine (MFM) consultation. Antibiotic coverage was started with intravenous (IV) ceftriaxone. She was noted to have right costovertebral angle (CVA) tenderness on exam.

She remained afebrile for 24 hours on antibiotics. She had improvement in the pain. She had no complaints. A plan was made for 14 days of Macrobid at discharge and ongoing suppressive therapy.

The day after admission she had an improved white blood cell count to 12.4. She had right sided CVA tenderness. She remained afebrile with stable vital signs. She was noted to have a bladder ultrasound with 500 cubic centimeters (cc) post void residual. She was to continued antibiotics and pain management. She was resting comfortably per the MFM note. She had one fever overnight at 101.7 degrees F. A cervical length was normal at 3.31 to 3.66 and the serum creatinine (Cr) was also normal. The pain was improving.

The last date of admission the white blood cell count was at 10.2 and the patient had a normal cr of 0.46. She was afebrile and had resolution of the CVA tenderness on the right side. She was transitioned to oral antibiotics and was discharged to home. A normal post void residual was noted on ultrasound on this date.
At issue is the medical necessity of an inpatient stay.

In this case, the patient was noted to have a urinary tract infection or pyelonephritis upon presentation to the hospital and assessment of the urine studies. There was no nausea or vomiting that would have prevented management at a lower level of care at the time of admission. There was no pelvic abscess suspected or confirmed by ultrasound imaging. The renal ultrasound was normal. There was no consideration of a surgical abdomen and the exam remained normal. There was also no endometritis as the patient was not delivered. There was no uterine tenderness or suspicion of amnionitis. There was no abdominal guarding or rebound to suggest peritonitis. There was no pelvic abscess on ultrasound imaging. There was no physical exam or suspicion of peritonitis given the normal abdominal exams. Thus, no criteria were met for inpatient admission in this case of a pelvic infection. Appropriate alternatives to admission would include outpatient care in emergency department, observation care, rapid treatment site, urgent care center, or medical office care. In this setting, intravenous (IV) antibiotics can be provided and the patient discharged to home. Outpatient management of pyelonephritis is safe and effective in pregnancy when there are no early warning signs which were absent in this case. In this case, after a review of the medical records and these care guidelines from the peer reviewed literature listed in the references, there was no medical necessity for admission to acute inpatient care.