Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI) with Pyelonephritis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is a school aged female child with medical history significant for constipation, inflammatory bowel disease, and vesicoureteral reflux status post-surgical repair a few years ago. She presented to the ED (emergency department) with symptoms of dysuria, fever to 103, abdominal pain, vomiting. She had been seen by the pediatrician the day before following onset of symptoms, was diagnosed with a urinary tract infection (positive urinalysis), and prescribed cefdinir. She was unable to tolerate the antibiotic, with recurrent vomiting. 
In the ED (emergency department), the patient's exam was significant for abdominal tenderness in the right lower quadrant and bilateral flank tenderness. Urinalysis was significant for leukocyte esterase, WBCs (white blood cells), blood, and protein. Blood work was significant for normal WBC (white blood cell) count 9.1K (thousand) with left shift 79%, elevated CRP (C-reactive protein) 10.4, mild metabolic acidosis with CO2 (carbon dioxide) 20. She was treated with Zofran, ibuprofen, acetaminophen, a normal saline bolus, and ceftriaxone. Renal and bladder ultrasound were unremarkable.
Admission orders included follow-up of cultures, continued IV (intravenous) antibiotics, antipyretics, IV (intravenous) fluids, and antiemetic. The patient continued to have fevers, with a slight decrease in her fever curve. She was treated with antipyretics. She had an episode of vomiting at dinner but was able to tolerate breakfast the next day. Urine culture from the pediatrician's office was negative to date. She continued on IV (intravenous) antibiotics and IV (intravenous) fluids. 

Fever curve continued to improve. She had nausea but no vomiting. She had a bowel movement. She continued to complain of dysuria, right lower quadrant pain, and right flank pain. The urine culture returned positive for E. coli (Escherichia coli). Because of fevers, she continued on IV (intravenous) antibiotics and IV (intravenous) fluids.
On the third day, the patient was afebrile for 24 hours, she was able to eat and drink, pain had resolved. She was deemed stable for discharge to start senna for constipation and complete her course of antibiotics with cefdinir. 

The Inpatient Hospital Admission was medically necessary. 

There are three categories of UTI (urinary tract infection): pyelonephritis, cystitis, and asymptomatic bacteriuria. Pyelonephritis indicates an infection involving the kidneys, and is characterized by systemic symptoms such as fever, nausea, vomiting, and malaise.  Pyelonephritis requires treatment for seven to fourteen days. Parenteral therapy indicated in sufficiently ill children, very young infants, and those unable to tolerate oral therapy. 

This young child with history of vesicoureteral reflux and pyelonephritis presented to the ED (emergency department) with pain, high fever, and vomiting. She was unable to tolerate the oral antibiotics prescribed the day before because of vomiting. She had failed outpatient treatment. She was admitted with complex urinary tract infection, symptoms of pyelonephritis, and refractory vomiting. She required parenteral antibiotic therapy. She remained hospitalized until her pain had resolved and she was afebrile for a day, both signs that the pyelonephritis was resolving. The care that was provided as well as the decision-making with history of failed outpatient therapy were most 
consistent with inpatient level of care. She could not have been managed at a lower level of care.