Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection, Sepsis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history significant for hypertension, diabetes mellitus, and neuromyelitis optica spectrum disorder who presented to the hospital with complaints of nausea, vomiting, diarrhea, and a throbbing headache that was associated with an intermittent cough and subjective fever. Her symptoms were relieved by Tylenol. The patient stated that her symptoms started after the injection of Semaglutide, which was prescribed for weight loss. The patient denied chest pain, shortness of breath, abdominal pain, flank pain, dysuria, vision changes, or tinnitus.
Upon initial evaluation in the emergency department, the patient was found to have a fever and tachycardia. When seen by the admitting physician the patient still remained tachycardic with a heart rate of 112 beats per minute (bpm), and the respiratory rate was 18 breaths per minute. Her temperature was 102.9 degrees Fahrenheit (F), and her oxygen saturation was normal.
The patient was obese. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits except for decreased visual acuity out of the left eye, which was chronic. The patient was tachycardic but had a regular heart rhythm and normal lungs. The abdomen was flat with normal bowel sounds; there was no abdominal tenderness. There was no costovertebral angle tenderness. A computed tomography (CT) scan of the abdomen and pelvis demonstrated fluid with stranding but no stones suggestive of pyelonephritis. The patient was admitted to the hospital with pyelonephritis, sepsis, type II diabetes mellitus, migraine headache, hypertension, and neuromyelitis optica spectrum disorder.
Subsequently, the urine culture came back positive for Escherichia coli and the patient was transitioned to intravenous Levaquin. The patient's clinical condition gradually improved and she was transitioned to outpatient care. At issue is the medical necessity of an inpatient level of care.

Based on the information provided, it was medically necessary for the patient to be admitted at the acute inpatient level of care for treatment of her urinary tract infection and sepsis. The patient met the systemic inflammatory response syndrome (SIRS) criteria suggestive of sepsis, including a temperature greater than 38 degrees Celsius (C) (100.4 degrees Fahrenheit (F)), heart rate over 90, and white blood cell count (WBC) over 12,000/cubic millimeters (mm3).
Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. Sepsis represents a spectrum of diseases with mortality risk ranging from moderate to substantial (eg, greater than (>) 40 percent (%)) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.
In general, the treatment of sepsis includes perfusion restoration with intravenous (IV) fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, and sometimes other supportive measures.
Additionally, the patient had an abnormal urinalysis indicative of a urinary tract infection. Sepsis is a life-threatening condition that requires timely and appropriate treatment. The treatment of sepsis typically involves restoring perfusion with intravenous (IV) fluids, administering broad-spectrum antibiotics, providing oxygen support, controlling the source of infection, and sometimes other supportive measures. To ensure that the patient received prompt and efficient treatment, admission at the acute inpatient level of care was the most appropriate course of action.