Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain, nausea, vomiting and fever
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the hospital via ambulance for abdominal pain, nausea, vomiting and fever. She had been diagnosed with pyelonephritis at another facility and urine culture showed pan-susceptible Klebsiella for which she was given cefpodoxime. She improved with this treatment but after stopping antibiotics, her symptoms returned. She had a past history of bariatric surgery six months prior. On questioning the patient, she did not have urinary symptoms or flank pain. No costovertebral angle tenderness was documented. She had a temperature of 100.1 Fahrenheit initially with a transient low blood pressure of 98/50 without drop in urine output or altered mental status. She also did not have any abdominal imaging done. Chest x-ray (CXR) was without acute infiltrate. White blood cell (WBC) count was elevated, with mild elevation in transaminases and normal creatinine. The patient was not in acute distress on examination. She was initiated on ceftriaxone 1 gram intravenously daily and was given intravenous fluids with anti-emetics. The next day, the patient had a fever of 101 Fahrenheit and had intermittent and non-sustained tachycardia. Ceftriaxone was continued and she was discharged on Day #2.

The proposed treatment is not medically necessary.

Medical necessity for inpatient hospitalization is established based on severity of illness and the medical probability of adverse events occurring with the patient's illness. A combination of comorbid conditions, symptoms, signs, laboratory data and imaging data inform risk assessment to determine the need for intensive treatment that can only be provided in the inpatient setting.

The patient did not have any serious comorbidity or unstable comorbidity. She did not have a history of cancer. She was a very low risk individual for adverse outcomes. Further, the patient had a normal examination in the emergency room and 
categorically denied flank pain and urinary tract symptoms. There was no documentation of costovertebral angle tenderness. No urinary tract imaging was undertaken to assess the risk of possible peri-nephric abscess or abnormality of the urinary tract. Kidney function was normal. Mental status was normal. No acidemia was present and no lactic acidosis was noted. The patient did not have hypotension persistently or tachycardia persistently. No respiratory compromise was noted. The patient's abdominal examination did not show any peritoneal signs or costovertebral angle tenderness documented. Liver function tests (LFTs) were marginally elevated without hyperbilirubinemia. This signifies a low-risk condition given lack of significant comorbidity, lack of organ dysfunction or change in mental status, and lack of hypotension or persistent tachycardia or tachypnea. A single or couple of measurements of blood pressure with mean arterial pressure over 65 millimeters of mercury (mmHg) do not signify hypotension in any meaningful clinical way. Blood pressure is a number, but different individuals have different baseline blood pressure that varies throughout the day and with activity. Selectively citing a low blood pressure measurement without the context of several normal and high blood pressure measurements on the same day as the purported low blood pressure measurement is not significant. The patient's isolate in urine culture was pan-susceptible and multiple oral antibiotics were available to treat it as an outpatient after a period of observation, along with anti-emetic treatment and assessment of response to treatment. The patient did not have persistent or intractable vomiting in the hospital or intractable pain requiring inpatient treatment.