Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder Infection.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult gravida 7 para 2-0-4-2 female who was admitted to the hospital for intravenous antibiotics due to a urinary tract infection at five weeks, three days of pregnancy. 
Two days prior to admission, an attempt was made to treat her urinary tract infection on an outpatient basis with nitrofurantoin, but the patient developed an itchy rash on her thighs and arms. She was treated as an outpatient with steroids and was referred for admission for treatment of her symptomatic urinary tract infection. Of note, the patient's past medical history was significant for a penicillin allergy which resulted in anaphylaxis. 
The patient was initially treated with intravenous aztreonam based on consultation with an infectious disease specialist. However, the patient also developed an allergic reaction to the aztreonam manifested as itching on her lower extremities with a visible macular raised rash on her thighs. She was given Benadryl and the antibiotic was changed to meropenem. She tolerated the meropenem and was discharged home in good condition without significant reaction to this antibiotic. The health plan denied the admission based on a lack of unstable vital signs, altered mental status, severe persistent symptoms, kidney transplant or pregnant with evidence of kidney infection, significant problems with kidneys or bladder, abscess, decrease in renal function, or inability to maintain oral intake and cites Milliman Care Guidelines (MCG) criteria for urinary tract infection. The facility contends that the admission was medically necessary based on severity of illness, sufficient intensity of resources, and medically necessary length of stay and cites Centers for Medicare and Medicaid Services (CMS) Benefits Policy Manual.

The proposed inpatient hospital admission was medically necessary.

It is essential to promptly and effectively treat urinary tract infections in pregnancy due to high risks of upper tract infection, sepsis, acute respiratory distress syndrome (ARDS), and prematurity in complicated urinary tract infection. The treatment of urinary tract infections in pregnancy is more difficult that in non-pregnant women because there is concern about possible effects of antibiotics on the developing fetus, particularly in the early first trimester as was the case for this patient. This patient's situation was further complicated by the fact that she had a history of serious allergic reaction to penicillin resulting in anaphylaxis. In general, there is concern about the use of many non-penicillin or cephalosporin antibiotics due to teratogenic concerns; exposure to nitrofurantoin, Bactrim, and fluoroquinones is not recommended by many authorities in the first trimester. Given the patient's life-threatening allergy to penicillin, there was a concern about possible cross reaction to cephalosporins. On the advice of the infectious disease consultant, the remaining alternatives required hospitalization for intravenous antibiotics. Therefore, the admission was medically necessary in order to give effective and safe treatment.