Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Genitourinary / Kidney Disorder.
Treatment:  Inpatient Hospital.

The insurer denied the inpatient hospital admission.  The denial was overturned in whole.

The patient is a female with a past medical history significant for atrial fibrillation, hypertension, gastroesophageal reflux disease (GERD), and cerebrovascular accident (CVA) with residual left upper extremity weakness, who presented to the emergency department with complaints of burning sensation while urinating, fever, and chills.   

The patient was prescribed Ciprofloxacin by the primary care physician for treatment of the urinary tract infection.  However, the patient did not take the medication because she did not like the taste of it.  According to the patient's family, the patient's condition continued to worsen.  It was reported that she lost 15 pounds in one month.  It was also reported that normally the patient ambulated with a walker, but lately she was unable to do it because of the weakness.  

At the time of the initial evaluation, the patient denied any cough, shortness of breath, chest pain, abdominal pain.  When seen by the admitting physician, the patient's temperature was 36.5 Celsius (C), blood pressure 143/56, respiratory rate 16, pulse rate 65 beats per minute (bpm), oxygen saturation 96% on room air.  The head, eyes, ears, nose, throat (HEENT) exam was within normal limits.  The neck was supple, nontender.  Lungs were clear to auscultation.  The cardiovascular exam was within normal limits.  The patient had a normal range of motion in her extremities.  She was awake, alert, and oriented.  Laboratory evaluation revealed that white blood cell count was 8.5, hemoglobin 10.8, hematocrit 32.7, platelets 272. Sodium was 136, potassium 3.9, chloride 98, bicarbonate 24, blood urea nitrogen (BUN) 13, creatinine 0.73, glucose 123.

The patient was admitted to the hospital with a diagnosis of sepsis due to urinary tract infection and dehydration.  It was mentioned that while in the emergency department the patient's temperature was 39.6C.  The patient was given a bolus of intravenous fluids while in the emergency department.  The patient was started on intravenous antibiotics, urine and blood cultures were sent.  At the time of admission, the patient was found to have elevated troponin that was attributed to demand ischemia. 

The patient was seen by the cardiology service and was recommended a rule out of acute coronary syndrome along with treatment of the urinary tract infection.  It was indicated in the follow-up note from the cardiology service that acute coronary syndrome was ruled out.

During the hospital stay the patient was also seen by an infectious disease specialist.  The infectious disease specialist diagnosed the patient was urinary tract infection and Penicillin allergy.  Therefore, treatment with intravenous Aztreonam was recommended.  During the hospitalization, the patient was seen by wound care service because of pressure ulcers in the left heel, right heel, and coccyx areas.  The patient was recommended to continue the pressure ulcer prevention strategy, topical wound care, and the continuing redistribution support surface.

The urine culture, as well as blood culture, came back positive for Escherichia coli.  During the hospital stay, the patient's clinical condition gradually improved.  She was switched to oral antibiotics and discharged from the hospital.  The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay was justified in this clinical case because the patient presented to the hospital with a sepsis syndrome due to untreated urinary tract infection.  The patient's symptoms and vital signs were consistent with sepsis syndrome.  Subsequently, the urine culture and the blood cultures came back positive for Escherichia coli, confirming the diagnosis.

Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection.  Common causes in immunocompetent patients include many different species of gram-positive and gram-negative bacteria.  Diagnosis is primarily clinical, combined with culture results showing infection; early recognition and treatment is critical.  In general, the treatment of sepsis includes aggressive fluid resuscitation, antibiotics, surgical excision of infected or necrotic tissue and drainage of pus, as well as supportive care.  Sepsis represents a spectrum of disease with mortality risk ranging from moderate (e.g., 10%) to substantial (e.g., greater than [>] 40%), depending on the various pathogen and host factors along with the timeliness of recognition and provision of appropriate treatment.

The general principles of sepsis treatment include:  1) Perfusion restored with IV fluids and sometimes vasopressors, 2) Oxygen support, 3) Broad-spectrum antibiotics, 4) Source control, and 5) Sometimes other supportive measures.

In this particular case, the patient was diagnosed with sepsis at the time of admission based on the clinical symptoms, previous history of untreated urinary tract infection, and positive SIRS criteria.  The positive SIRS criteria included temperature greater than 38C and heart rate greater than 90 bpm, which were noted at the time of the initial evaluation in ER.  In conjunction with the patient's symptoms of urinary tract infection and abnormal urinalysis, the patient qualified for the diagnosis of sepsis.  Therefore, it was extremely important to admit the patient to the hospital and initiate treatment with intravenous antibiotics and intravenous fluids, as well as to perform very close monitoring for signs of possible hemodynamic instability.  Since sepsis is a serious medical condition with a relatively high mortality rate if inadequately treated, the care should have been provided in acute inpatient settings.