Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Stay. 
The denial is Upheld in whole.

In this case, the patient was a female who presented at 24-0/7 weeks gestational age. The patient had a singleton gestation. She had no prior obstetric history this was her first pregnancy. The patient was given a diagnosis of urinary tract infection in the emergency department and had never received antibiotics. Her most recent evaluation in emergency room was weeks earlier when she was not treated.

The patient presented with right flank pain, nausea, and dysuria since Sunday. The patient's examination was noted to be normal. Her abdomen was soft, nontender and nondistended with bowel sounds present. The uterus was gravid with a size appropriate for dates without fundal tenderness. There is no cervical motion tenderness. The fetal heart rate was normal and category 1 with a reassuring fetal monitoring strip. An ultrasound was performed which noted fetal heart rate activity to be present and a cervical length of 36 millimeter (mm). There is a singleton gestation present with a biophysical profile score of 8 of 8 which was reassuring.

The patient was given a diagnosis of pyelonephritis given flank pain and positive costovertebral angle tenderness on the right with dysuria. It was known that the patient had a previous urinary tract infection in the previous month that had not been treated. The patient was afebrile and was started on intravenous (IV) fluid resuscitation. Group B swab was also collected. The patient was started on ceftriaxone for treatment. The patient was admitted to antepartum unit with a diagnosis of pyelonephritis. The patient was seen by the consultation medicine service which noted that she had a four-day history of right-sided abdominal pain which was described as sharp pain that is continuous and unremitting that was not relieved by anything. 

Two days after admission the patient denied shortness of breath, chest pain, dizziness, headache, visual disturbance, pain or nausea or vomiting. She had no vaginal bleeding or leakage of fluid and reported good fetal movement. She was tolerating a regular diet and ambulating without difficulty. Her examination was noted for abdominal pain in the lower abdomen. She had no dysuria present and no vaginal bleeding.The patient remained afebrile at that time and a repeat cervical length was planned the urine culture had come back positive for Escherichia coli that was susceptible to ceftriaxone. The patient was on regular diet. The patient was discharged to home with follow-up scheduled in outpatient setting. The medical necessity for the inpatient stay is the subject under review.

The health plan's determination is upheld in whole.

In this case, the medical records were reviewed in concert with the recommendations from peer reviewed literature for the management of pyelonephritis and urinary tract infection in pregnancy and the Milliman Care Guidelines (MCG) Care Guideline entitled "Preterm Labor, Threatened". In this case, the patient presented with known untreated urinary tract infection that had progressed to pyelonephritis. She was started on IV Rocephin and urinary cultures were obtained.  Based upon these charted aspects of care, the care as provided would be appropriate at a lower level of care given the interventions of IV fluids, monitoring, IV Rocephin and absent signs and symptoms of pregnancy complications. Thus the patient have been treated at a lower level of care status.