Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI)
Treatment: Inpatient hospital admission
The insurer denied inpatient hospital admission.
The determination is upheld. 

The patient is a female child with medical history significant for sickle cell trait, neonatal exposure to maternal human immunodeficiency virus (HIV), chronic constipation, seizure disorder, moderate persistent asthma, and frequent urinary tract infections (three prior infections all culture negative in the past year) that presented to the emergency department (ED) in the early morning for evaluation of crying during urination. She had been seen by her pediatrician the previous day where urine had been collected. She reported abdominal pain for three days but no nausea or vomiting. Urinalysis from the clinic was significant for pyuria.
Laboratory evaluation was significant for a white blood cell (WBC) count at 9.4, hemoglobin was 11.4, unremarkable metabolic panel, negative rapid viral screen, lactate was 0.7, and unremarkable urinalysis. She was treated with intravenous (IV) fluids, Tylenol/Motrin, and ceftriaxone prior to transfer to the pediatric floor for further management.
She was deemed stable for discharge home to complete a seven-day course of Bactrim, obtain an ultrasound in the outpatient setting, and consult with Pediatric Gastroenterology for chronic constipation.
At issue is the medical necessity of inpatient hospital admission.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
Urinary tract infection (UTI) is a common diagnosis in infants, children, and adolescents. Pathogenesis is multifactorial, and may result from dysfunctional voiding (e.g., constipation, neurogenic bladder, irritation from bubble baths), instrumentation (e.g., foley catheter placement), turbulent flow from voiding abnormalities (e.g., hydronephrosis, vesicoureteral reflux), or hematogenous spread (e.g., neonates and young infants). 
Presentation of infection varies by age and degree of infection.  Enuresis may also occur in previously continent children. Pyelonephritis may present with high fever, back or flank pain, and fatigue, in addition to urinary symptoms. Examination may reveal ill appearance, costovertebral angle tenderness, and abdominal tenderness. Urinalysis may reveal pyuria, bacteriuria, nitrites, leukocyte esterase, and hematuria. Additional lab studies should also be considered depending on clinical presentation.
For neonates and young infants, hospitalization for treatment with parenteral antibiotics is necessary. Older patients that appear ill or dehydrated, or in whom there is possibility of urosepsis, or underlying disease also require hospitalization. Older children can typically be treated with enteral antibiotics, with duration of therapy dependent upon age and extent of infection (cystitis versus pyelonephritis). Imaging studies are not routinely necessary. However, for infants and young children with first febrile UTI, renal ultrasound is recommended to identify potential pathology. Voiding cystourethrography is indicated in the second febrile UTI to rule out reflux unless history warrants earlier studies.
This young female child with a history of constipation and frequent (culture-negative) urinary tract infections presented with clinical urinary tract infection, and culture positive for Escherichia (E.) coli. Because of recurrent infection and somewhat atypical outcome, it was not unreasonable to monitor her overnight pending culture and sensitivity results treating with parenteral antibiotics. However, she was overall hemodynamically stable with no evidence of significant dehydration and no metabolic derangements. She did not require acute inpatient admission and could have been safely managed at a lower level of care.