Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection.
Treatment: Inpatient hospital stay.

The health plan denied the inpatient hospital stay as not medically necessary.  The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for intravenous drug abuse who presented to the emergency department with complaints of subjective fever, back spasms, nausea. Her symptoms started one night before the presentation. At the time of evaluation, the review of systems was positive for fever up to 100.2Fahrenheit, nausea, rigors, and back muscle spasms. The patient denied vomiting, diarrhea, bladder/bowel incontinence, abdominal pain, dysuria, hematuria, or any other symptoms. Laboratory evaluation revealed that white blood cell count was 11.1, hemoglobin 11.1, hematocrit 33.4, platelets 254. Sodium was 134, potassium 3.5, chloride 101, bicarbonate 27, blood urea nitrogen (BUN) 21, creatinine 0.82, glucose 96. Chest x-ray was negative for the acute disease process. An electrocardiogram (EKG) revealed sinus tachycardia with a rate of 111.

It was reported that the patient was previously admitted to the hospital because of sepsis and epidural abscess. She was found to have bacteremia and underwent a transthoracic echocardiogram, which demonstrated vegetations consistent with endocarditis. She was also diagnosed with Lumbar (L)5 - Sacral (S)1 epidural abscess associated with discitis. In the hospital, the patient underwent a magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine, which showed mild improvement in the L5 - S1 osteomyelitis with stable, mildly resolving phlegmon. There was no evidence of spinal cord impingement. Blood cultures remained negative, and antibiotics were discontinued. The urine culture came back positive, and the patient was sent home with a recommendation to finish a three-day course of ciprofloxacin.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.

This patient presented to the hospital with subjective fever, chills, back muscle spasms. Considering the patient's previous medical history significant for discitis and osteomyelitis, it was reasonable to admit this patient to the hospital to perform a workup to determine if these symptoms were related to the previously mentioned conditions.

However, the workup showed improvement in these previously diagnosed conditions, and the patient did not require any interventions including surgical procedures or continuation of treatment with intravenous antibiotics. The patient had a urinary tract infection (UTI).

Based on the accepted standards of care, admission to the hospital at the acute inpatient level of care for treatment of urinary tract infection is justified in cases of hemodynamic instability, severe or persistent vomiting, altered mental status that is severe or persistent, or worsening fever, pain, or need for parenteral antibiotics. The admission at the acute inpatient level of care in cases of urinary tract infection is also indicated for immunocompromised patients, cases of new coagulopathy, acute renal failure, or when patients need intravenous hydration support, as well as some other medical problems.

The review of the medical records clearly demonstrated that the patient had none of the circumstances listed above.

Therefore, the admission at a lower level of care to establish the correct diagnosis and define the appropriate treatment regimen was the most appropriate, given the clinical circumstances.