Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection, Sepsis

Treatment: Acute inpatient stay

The insurer is denied coverage for the acute inpatient stay.
The denial is upheld.

This is a female patient who presented to the emergency room (ER) with complaints of abdominal pain, fever, chills, and left flank pain. Initial emergency room (ER) vital signs were blood pressure 110/84, pulse 171, respirations 20, temperature 103.1F, and blood oxygen level 98% on room air. The patient reported she completed a 10-day course of Macrobid for a urinary tract infection (UTI). Her white blood cell (WBC) count 6.01, hemoglobin 10.9, platelets 131, aspartate aminotransferase (AST) 58, lactate 4.5, amylase 85, lipase 49, glucose 167, and potassium 3.3. A urinalysis was positive for ketones 1+, blood 1+, protein 2+, and leukocytes 3+. Influenza testing was negative. 

A computed tomography (CT) of the abdomen and pelvis showed possible bladder wall thickening which may be seen in the setting of cystitis, and mild fullness of the right renal collecting system without evidence of obstructing stone. An abdominal X-ray showed a nonspecific bowel gas pattern. An electrocardiogram (EKG) showed sinus tachycardia. She was treated with intravenous (IV) fluids, IV antibiotics, Acetaminophen, Ketorolac, and Pantoprazole. The patient was admitted to the hospital with diagnoses of sepsis and pyelonephritis with failed outpatient regimen for urinary tract infection. Intravenous (IV) fluids and IV antibiotics were continued. A repeat lactate was 1.7. She had continued intermittent fevers during her stay. Blood cultures were negative. The patient's symptoms improved and she was discharged.

Per Belyayeva, M; Jeong, J.M. (2020), "Acute pyelonephritis can be managed as either outpatient or inpatient. Healthy, young, non-pregnant women who present with uncomplicated pyelonephritis can be treated as outpatients. Inpatient treatment is usually required for those who are very young, elderly, immunocompromised, those with poorly controlled diabetes, renal transplant, patients, patients with structural abnormalities of the urinary tract, pregnant patients, or those who cannot tolerate oral intake. The initial selection of antibiotics will be empiric and should be based on the local antibiotic resistance.

Per Long, B., & Koyfman, A. (2018), "Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis."

Per Johnson, J. R. and Russo, T.A. (2018), "Decisions regarding disposition and treatment in patients with pyelonephritis should be guided by assessment of the likelihood of pathogen resistance to antimicrobial agents and by patient factors (e.g., illness severity, coexisting conditions, and psychosocial situation)."

The acute inpatient stay is not considered medically necessary for this patient as the patient's care could have been provided at a lower level of care such as observation. The submitted documentation does not support the criteria for an acute inpatient stay.

Based on the above, the medical necessity for the acute inpatient stay is not substantiated. The insurer's denial is upheld.