Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Genitourinary/Kidney Disorder-UTI-pyelonephritis
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned the health plan determination in whole.

This is the case of a non English-speaking family with a pediatric patient at the time of service previously healthy  who presented to the emergency department with fever, sore throat, and gross hematuria x 2 days. Patient denies dysuria or urinary frequency, also denies back pain. The review of symptoms was positive for periumbilical abdominal pain, fever, sore throat, and red-colored urine. Home medications included over-the-counter (OTC) cough/cold preparation. Per further history taking, this patient had similar episodes of red urine in the past that self-resolved.  ED vitals were Temperature 37.6 Celsius, heart rate (HR) 109, respiratory rate (RR) 18, blood pressure (BP) 121/88, and oxygen (O2) saturation 96% on room air. Physical exam was normal except for the notation of gross hematuria and left costovertebral angle (CVA) tenderness. A urinalysis (UA) showed red urine with specific gravity (SG) 1.029, potential hydrogen (pH) 7.0, 300 protein, large blood, positive nitrites, and moderate leukocyte esterase. Labs were white blood cell count=21.8 with 82% segs and 10% lymphocytes, hematocrit (Hct)=40, platelets (Plt)=318. Electrolytes were normal with anion gap (AG)=15, Creatinine=0.48. Renal/bladder ultrasound showed no hydronephrosis. There was decreased vascularity in the mid to upper pole region of the left kidney which is a non-specific finding but could reflect pyelonephritis. The patient was diagnosed with tubulo-interstitial nephritis, was started on ceftriaxone and admitted to the hospital for intravenous antibiotics and further management. The patient was admitted and urology was consulted. Urology consult agreed with diagnosis of probable pyelonephritis and plan to continue intravenous fluids and antibiotics, and recommended nephrology follow-up. Urine and blood cultures were no growth, labs including creatinine remained stable and hematuria resolved. Antibiotics were stopped and the patient was discharged home with appropriate outpatient follow-up.

The requested inpatient hospitalization was considered medically necessary for this patient. This is a pediatric patient who presented with gross hematuria, fever, and flank pain. This clinical examination and diagnostic workup indicated probable pyelonephritis, supporting initial treatment with IV antibiotics and admission to the hospital for further management. In addition, this patient had concern for underlying renal disease or pathology, as indicated by the history of prior episodes of gross hematuria. There was also a language barrier with primary non-English language spoken, a possible barrier to adequate outpatient care and follow-up. Therefore, given the clinical presentation and additional case details, inpatient admission for this child was medically warranted.
As indicated above, both the clinical and social presentation warranted inpatient admission for initial treatment and management. This child had acute symptoms indicating invasive disease, as well as history concerning for underlying pathology due to recurrence of symptoms.  Given the medical documentation provided, the hospital course was appropriate and medically warranted until diagnostic work-up was complete.