Appeal type: Medical necessity
Decision: Upheld

Genitourinary /Kidney Disorder - Urinary Tract Infection (UTI)
Inpatient Hospital

The patient is a female with past medical history of asthma who presented to the emergency room (ER) with chief complaint of right-sided flank pain for 10 days and fever for 9 days with associated urinary frequency. On presentation, temp was 102.2 with heart rate (HR) 107, respiratory rate (RR) 21, blood pressure (BP) 115/69, with oxygen saturation of 100% on room air (RA). Exam otherwise noted tenderness in the right flank area. Labs showed white blood cell (WBC) count 7.5, Hemoglobin (HGB) 11.9, platelets (Plt) 192, sodium (NA) 137, potassium (K) 3.4, blood urea nitrogen (BUN) 7, creatinine (Cr) 0.88, lactic acid normal. Urinalysis (UA) noted + nitrite, large blood, moderate leukocyte esterase (LE), greater than (>)100 WBCs, and moderate bacteria. Abdominal ultrasound (US) showed no hydronephrosis. The patient was brought into the hospital with assessment that she had a urinary tract infection (UTI) and plans for intravenous fluids (IVF) and intravenous (IV) antibiotics. 

The following day the temp was 100.4 with HR 70s-90s, RR 18, SBPs 90s to 110s. The patient continued to have right flank pain. Urine culture noted gram negative rod (GNR) with identification (ID) pending. Plan was to add ampicillin in addition to ceftriaxone (CTX) and pursue pelvic US. Pelvic US subsequently showed small amount of non-specific free fluid. 

The next day, temperature maximum (Tmax) was 99.2. Blood cultures showed no growth for 48 hours. WBC was 6.4. Urine culture (UCX) was noted to show Escherichia E. Coli that was pan sensitive. UA was repeated and had improved. Assessment was that the patient continued to have 1/10 costovertebral angle (CVA) tenderness without nausea of vomiting and with plans to continue the same treatment, encourage the patient not to hold her urine, and to discharge her when her pain was better. The patient was discharged the next day.The issue in question is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

This is a young patient without past medical history who presented with dysuria, flank pain, and fever with mild tachycardia in the setting of positive UA and concern for pyelonephritis. She did not have associated leukocytosis, nausea/vomiting (N/V), history of UTIs with resistant organisms, urinary tract anomaly placing her at risk of complications, emphysematous pyelonephritis, uncontrolled diabetes mellitus (DM) or other immunocompromising co-morbidity increasing her risk of complications or associated renal failure. Given this, it was anticipated on presentation that she would likely recovery quickly. Indeed, her vital signs normalized quite quickly, she was afebrile with UCx growing pan-sensitive E. Coli, blood cultures negative, and was felt appropriate to be able to be able to discharge on oral antibiotics (abx). She stayed on beyond a reasonable period of 48 hours of observation in the setting of 1/10 flank pain but in the absence of severe pain requiring IV pain medications, ongoing hemodynamic instability, N/V, inability to take oral antibiotics, ongoing leukocytosis or other new acute process, an inpatient stay was not medically necessary.