Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with history of depression and obsessive-compulsive disorder (OCD) who presented to the emergency department (ED) with pelvic pain, chills, aches, and dysuria.  She had a temperature of 100.1, mildly tachycardic at 104, and was hypotensive.  She was given intravenous fluids and worked up for sepsis.  She reported a possible sexual assault two days prior when she was partaking in drug use.  She declined the sexual assault testing.  The patient had a computed tomography scan which revealed non-obstructing kidney stones and ovarian cysts.  She had blood and urine cultures obtained.  She was started on intravenous ceftriaxone, cefoxitin, Flagyl, and doxycycline.  She was given Toradol for pain.  She had an elevated white blood cell count.  Her urine also returned with Escherichia (E) coli.  She was admitted to the gynecology service with concerns for pelvic inflammatory disease (PID) and sepsis.  She continued to have pain and fevers.  An ultrasound was performed which revealed simple bilateral ovarian cysts and not tubo-ovarian abscess (TOA).  The diagnosis was changed to sepsis from acute pyelonephritis, not pelvic inflammatory disease (PID).  On the second day, the patient's white blood cell count had decreased, her pain was improved, and she was afebrile.  She was discharged home with oral antibiotics and outpatient follow up.

The proposed inpatient hospital admission was medically necessary.

According to Workowski, most women with pelvic inflammatory disease (PID) can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:
- Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain, sepsis)
- Complicated pelvic inflammatory disease (PID) with pelvic abscess (including tubo-ovarian abscess)
- Possible need for invasive diagnostic evaluation for alternate etiology (e.g., appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
- Inability to take oral medications due to nausea and vomiting
- Pregnancy
- Lack of response or tolerance to oral medications
- Concern for non-adherence to therapy

There has been a persistent trend towards outpatient treatment of pelvic inflammatory disease (PID) with only the minority of women being hospitalized. Support for outpatient therapy for mild or moderate pelvic inflammatory disease (PID) comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (ie, PEACH trial). In that trial, 831 women with lower abdominal pain, uterine or adnexal tenderness, and mucopurulent cervicitis or untreated gonococcal or chlamydial infection were randomly assigned to inpatient therapy with intravenous cefoxitin for at least 48 hours plus doxycycline or outpatient therapy with a single intramuscular dose of cefoxitin with probenecid plus doxycycline. Short-term clinical and microbiologic outcomes and long-term reproductive outcomes (e.g., ectopic pregnancy, chronic pelvic pain) were similar between the two groups.

In review of the medical record, this patient presented with pain, low grade fever, and sepsis.  This is a severe clinical scenario which meets the literature criteria for admission.  Therefore, although the trend has been to treat as an outpatient, given the patient's diagnosis of sepsis, the inpatient admission was necessary.  There is a high rate of morbidity and mortality in the setting of sepsis.  Therefore, the admission was medically necessary.  This was the most appropriate level of care, not a convenience, and not more costly than alternative options.