Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, shortness of breath, chills, cough, and urinary frequency.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

This male was admitted. The patient has a history of hypertension (HTN),
hyperlipidemia (HLD), obstructive sleep apnea (OSA) and myocardial infarct (MI).
The patient presented to the emergency room (ER) complaining of fever, shortness
of breath (SOB), chills, cough, and urinary frequency. He was seen in the
emergency department and influenza and COVID were negative.

The patient's vital signs (VS) included: temperature 102.3, pulse 107, respiratory
rate 26, blood pressure 118/55 and oxygen saturation 97%. Exam was
unremarkable. Labs revealed: white blood cell (WBC) 18, hemoglobin/hematocrit
(H/H) 10.3/21.2, platelets (Plt) 449, sodium (Na) 140, potassium (K) 4.5, carbon
dioxide (CO2) 29, blood urea nitrogen (BUN) / creatinine 18.5 / 0.9, D-dimer 2143,
and troponin 0.18. Urine analysis (U/A) showed pyuria.

The patient was admitted with sepsis, rule out COVID. Intravenous (IV) antibiotics
were started. Day 2, vital signs were stable and the patient was afebrile. White
blood cell (WBC) count was 15.6. Cardiology consult diagnosed the patient with
demand ischemia due to infection and did not recommend further cardiology work
up. Infectious Diseases (ID) recommended continuing intravenous (IV) antibiotics
for urinary tract infection (UTI).

Day 3, vital signs were stable and the patient was afebrile. The patient was awake
and comfortable. COVID was negative. The patient was continued on intravenous
antibiotics.

Day 4, vital signs were stable. Maximum temperature (Tmax) was 102. The
patient's cough improved. Urine culture revealed Escherichia (E) coli. White blood
cells (WBC) were decreasing. Blood cultures were negative. Chest x-ray had
nothing abnormal detected (NAD). Plan was for computed tomography (CT) and
repeat cultures. The patient was continued on intravenous antibiotics.

Day 5, vital signs were stable and the patient was afebrile. COVID was negative
times two. Plan was for renal and urinary sonogram and Urology consult to rule
out prostatitis.

Day 6, vital signs were stable and the patient was afebrile. Urology consult was
pending.

Day 7, vital signs were stable and maximum temperature was 100.4. Urology
consult was pending.

Day 8, vital signs were stable and the patient was afebrile. COVID was negative
times three. The patient had mild hydronephrosis and cysts on sonogram. Urology
recommended cystoscopy as an outpatient.

Day 9, vital signs were stable and the patient was afebrile. Computed tomography
(CT) revealed ground glass infiltrates.

Day 10, vital signs were stable and the patient was afebrile. He had elevated white
blood cells (WBCs) due to steroids. He was changed to oral (PO) antibiotics and
was cleared for discharge to home.

No, the proposed inpatient admission was not medically necessary.
Medically necessary services are those which are:
1) safe. 2) effective. 3) generally accepted national standard of medical practice. 4) not provided primarily for convenience of the patient or the practitioner. 5) the least intensive and/or most appropriate alternatives among diagnostic and
treatment option.

The requested inpatient admission was not medically necessary because it was not
in accordance with generally accepted national standard of medical practice.

This patient was admitted with suspected sepsis. Evaluation in the emergency
department (ED) showed the patient to be be febrile and have tachycardia and
tachypnea. Studies showed leukocytosis and pyuria. He did not have altered
mental status. He did not have bacteremia. He did not have acute kidney injury
(AKI). The patient was admitted and treated with intravenous antibiotics for urinary
tract infection. He had not failed an observation level of care. He remained hemodynamically stable during hospital stay with intermittent fever. The patient's
tachycardia and tachypnea had resolved. He remained on intravenous antibiotics
while undergoing genitourinary (GU) work up for fever. The acute inpatient
admission was not medically necessary. The patient did not have fever greater
than or equal to 103; did not have acute kidney injury or electrolyte abnormalities;
and had not failed a lesser level of care.