Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Inpatient Hospital Stay. The insurer denied inpatient hospital stay.
The determination is overturned.

The patient has a past medical history significant for gestational hypertension and multiple urinary tract infections. She presented to the hospital with complaints of abdominal pain and subjective fever. The patient stated that her pain started one day before the day of the presentation while she was moving furniture. It was located in the flank areas bilaterally with radiation to the chest, back, lower abdomen. The pain was sharp and worsened with urination. The patient noticed subjective fever, loss of appetite, nausea, and vomiting.
It was mentioned that just three days before the day of admission the patient was seen in the emergency department with complaints of abdominal pain. Reportedly she was given pain medications and released from the emergency department on the same day. It was also mentioned that patient's urinalysis on that day was positive but she never was treated with antibiotics.
At the time of the presentation, the patient's temperature was 37.8 Celsius (C), blood pressure 116/74, heart rate 91, respiratory rate 20, and oxygen saturation 100%. The patient appeared to be a young female who was in no acute distress.
The cardiac exam revealed a systolic murmur. Lungs were clear to auscultation. The abdominal exam revealed right/left/lower abdominal tenderness with palpation. There was no guarding or rebound. The abdomen was distended, there were hyperactive bowel sounds. The rest of the physical exam was unremarkable. A computed tomography (CT) scan of the abdomen and pelvis demonstrated right pyelonephritis without evidence of obstruction.
The patient was admitted to the hospital with a diagnosis of acute pyelonephritis and failure of outpatient treatment. The patient started on intravenous antibiotics, urine culture was obtained. The patient received treatment with pain medications, antiemetics, intravenous fluids.
As a result of the treatment, the patient's symptoms improved, including the resolution of fever and improvement in her flank pain.
During the hospital stay, the patient remained hemodynamically stable, her oral intake improved. Therefore, she was discharged from the hospital in stable clinical condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment was medically necessary for this patient at the acute inpatient level of care. This patient had acute pyelonephritis that was accompanied by nausea and vomiting.
The main treatment of acute pyelonephritis includes the administration of antibiotics. In general, outpatient treatment of acute pyelonephritis is possible unless patients are immunocompromised, have persistent nausea and vomiting, are volume-depleted, or have a complicated urinary tract infection. In this clinical case, the patient presented with recurrent episodes of nausea and vomiting that jeopardized treatment with oral antibiotics and increased the probability of dehydration.
Therefore, even though the patient was hemodynamically stable and had no clinical signs of sepsis, she still required admission at the acute inpatient level of care for the administration of intravenous antibiotics and pain medications and close monitoring. According to the notes, the patient still felt nauseous after the initial treatment provided in the emergency department.
Even though she was not immunocompromised and had no clinical signs of sepsis, the patient continued to have nausea following the initial period of treatment in the emergency department, therefore she required treatment with intravenous fluids and intravenous antibiotics as well as close monitoring. This kind of treatment requires admission at the acute inpatient level of care.