Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection. 
Treatment: Full Hospital Admission. 

The insurer denied the full hospital admission. 
The health plan's determination is overturned. 

The patient is a female with a past medical history of hypertension and hyperlipidemia who presented to her physician with a fever and chills for three days. The physician found her temperature to be 103 degrees Fahrenheit (F) and immediately advised her to go to the emergency room for further evaluation. The patient complained of feeling nauseous and experiencing dysuria and burning during micturition. She also reported feeling constipated, with her last bowel movement being a week before. The patient admitted to having night sweats but denied weight loss or recent travel. She mentioned that she had caught Coronavirus (COVID-19) a few months ago and had suffered from dry cough since. She denied chest pain, shortness of breath, abdominal pain, or diarrhea. 

In the emergency room (ER), the patient had a positive urinary analysis and tenderness in the right flank. The patient met sepsis criteria, with a blood pressure (BP) of 157/84, a pulse of 119, a temperature of 101.7 F (Oral), a respiratory rate of 24, a peripheral capillary oxygen saturation (SpO2) of 97 percent (%), and a body mass index (BMI) of 32.61 kilograms per meters squared (kg/m2). 

The physical examination revealed that the patient was not in acute distress, was pleasant, and was an obese female lying comfortably in bed. The patient's head was normocephalic and atraumatic, and the extraocular movements were intact. Her pupils were equal, round, and reactive to light. The cardiovascular system had a normal heart rate and regular rhythm, with normal pulses and heart sounds. The pulmonary system had normal effort and breath sounds. The abdomen was soft and flat, with right costovertebral angle tenderness. The neurological examination showed no focal deficit, and her mental status was at baseline. 

Additional laboratory studies were sent, and the nephrology service was consulted again. The patient's troponin was elevated, which was attributed to demand ischemia due to severe sepsis and acute kidney injury. Another clinical diagnosis was normocytic anemia and constipation. During the hospital stay, the patient's clinical condition gradually improved, and she was transitioned to outpatient care. 

The admission at the acute inpatient level of care was medically necessary. The nephrology service was consulted due to the patient's renal failure, and they recommended starting gentle hydration and workup for the cause of renal injury. Based on the workup, the cause seemed to be likely intrinsic acute kidney injury (AKI). The infectious disease service was consulted regarding possible pyelonephritis and community-acquired pneumonia and recommended continuing Ceftriaxone and adding Doxycycline. Later on, infectious disease (ID) said that the patient could be discharged on oral Cefuroxime and Doxycycline for five more days of therapy. Pulmonology was consulted regarding possible community acquired pneumonia and recommended a short course of prednisone for her cough, as well as outpatient pulmonary function tests (PFTs) and polysomnography. 
Based on the evaluation, the patient had sepsis due to a urinary tract infection. Sepsis is a life-threatening condition that requires prompt and effective treatment, which is best provided at an acute inpatient level of care. Delay or inadequate treatment can lead to significant morbidity and mortality. Therefore, admitting the patient at an acute inpatient level of care was a necessary and appropriate decision. 
Milliman Care Guidelines (MCG) Health Inpatient &amp; Surgical Care 26th Edition criteria for urinary tract infection were attached to the chart and carefully reviewed. 

The health plan's determination of medical necessity is overturned in whole.