Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder. Treatment: Inpatient Hospital. The insurer denied inpatient stay. The denial is overturned in whole.

The patient is a female who presented to the emergency department with complaints of dysuria, body aches, chills, weakness, and fever that started approximately 5 days before the presentation. The patient stated that she went to see her primary care physician and received a prescription for Levofloxacin. Reportedly, the patient took the antibiotic for one day and found no relief of her symptoms, therefore she came to the emergency department.

On the physical exam, the patient's temperature was 36.8 Celsius (C), heart rate was 101 beats per minute (bpm), blood pressure was 105/70, and oxygen saturation was 96% on room air. The patient was in no acute distress. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The patient had no cervical adenopathy or jugular vein distention (JVD). Lungs were clear to auscultation bilaterally. The cardiovascular exam was within normal limits. The abdominal exam showed normal bowel sounds with no masses, organomegaly, or tenderness. On the neuro exam, the patient was oriented to person, time, and place. Cranial nerves were within normal limits. The patient had normal strength in her extremities and normal reflexes.

The patient was admitted to the hospital with a diagnosis of pyelonephritis and sepsis. The patient received treatment with Ceftriaxone. Urine culture was sent. As a result of the treatment, the patient sustained clinical improvement and was subsequently switched to oral antibiotics to complete the 10-day course.

The health plan's determination is overturned, in whole.

The inpatient stay was medically necessary since the patient presented to the hospital with acute pyelonephritis associated with sepsis syndrome.

According to the accepted standards of care, patients with sepsis should be admitted to the hospital. Inadequately treated sepsis is associated with a significantly increased risk of mortality.

In order to decide if this patient required admission at the acute inpatient level of care, systemic inflammatory response syndrome (SIRS), Sepsis, and Septic Shock Criteria was utilized. This is a risk stratification tool that defines the severity of sepsis and septic shock. Based on the calculations, the patient met sepsis criteria. The positive SIRS criteria included heart rate greater than (>) 90, WBC > 12,000/mm3, and clinical evidence of acute pyelonephritis.
Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection.

Sepsis represents a spectrum of disease with mortality risk ranging from moderate to substantial (e.g., > 40%) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.

In general, the treatment of sepsis includes perfusion restoration with intravenous (IV) fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, sometimes other supportive measures.

In order to provide treatment for patients with sepsis in the most efficient way in a timely manner, the admission at the acute inpatient level of care is the most appropriate.