Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Flank Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient is a gravida (G) 1 para (P) 0 with left flank pain. She was noted to have a normal blood pressure of 123/67, normal heart rate of 112 for pregnancy, normal peripheral capillary oxygen saturation (SpO2) of 98% on room air, and normal temperature of 36.9 degrees Celsius (C). Her cervix was long, closed and fetal presentation was high. She had reassuring fetal testing with a baseline of 155, moderate variability and no decelerations. This was reassuring and there were no contractions. An ultrasound was performed and noted normal fluid and a biophysical profile score of 8/8 that was reassuring. The patient was also taken to ultrasound for a formal renal ultrasound given her flank pain. The fetal status remained reassuring throughout the hospitalization. A Group B Streptococcus (GBS) swab was collected on the patient.
An ultrasound of the kidneys noted bilateral renal hydronephrosis and absent renal masses or stones. There were no stones noted in the bladder. There were normal urethral jets noted. Antibiotics were given as intravenous (IV); Rocephin 1 gram x 2 doses 24 hours apart.
The white blood count was normal for pregnancy at 11.45 with a normal hemoglobin of 11.1 grams per deciliter (g/dL). The differential was also normal on the complete blood count. A urine drug screen was negative. The thyroid stimulating hormone (TSH) was mildly elevated with a normal free T4. The urinalysis was normal without signs of infection. The blood type was O positive and screen was negative. A urine culture was negative and the GBS culture was also negative. At discharge, the patient was started on Keflex 500 milligrams (mg) twice per day for the diagnosis of urinary tract infection. She was also to be on Tylenol as needed for pain. She was given precautions and follow up in the outpatient setting. At issue is the medical necessity of an inpatient stay.
Based upon a review of the medical records and the Milliman Care Guidelines (MCG) entitled "Obstetric and Gynecologic Disease GRG" and the peer reviewed literature, the requested health service/treatment of inpatient stay would not be considered medically necessary in this case. The MCG Health Guidelines with the following criteria for medical necessity for admission to inpatient care in the case of pelvic or obstetric infection:
"Admission is indicated for conditions covered by this guideline for 1 or more of the following:

**Pelvic infections requiring hospitalization; indications include 1 or more of the following:
1) Failure of, inability to follow, or unavailability of outpatient regimen. 2) Vomiting precluding outpatient and observation care management. 3) Pelvic abscess. 4)Presentation such that surgical emergency cannot be excluded (eg, surgical abdomen).

**Obstetric infection requiring hospitalization; indicators include 1 or more of the following:
1) Endometritis (except mild postpartum endometritis). 2) Amnionitis. 3) Peritonitis. 4) Septic pelvic thrombophlebitis. 5) Pelvic abscess. 6) Suspected peritonitis or ectopic pregnancy requiring monitoring beyond the scope (eg, over 24 hours) of observation care".

In this case, the patient was noted to have a urinary tract infection or possible pyelonephritis upon presentation to the hospital and assessment of the physical exam. The urine studies were negative at presentation and culture was negative. There was no evidence of a renal stone or pathology by ultrasound. The pregnancy was incidental to presentation given reassuring fetal testing and lack of contractions or concerns for preterm labor. The There was no nausea or vomiting that would have prevented observation of care management at the time of admission. There was no pelvic abscess suspected or confirmed by ultrasound imaging. The renal ultrasound was normal. There was no consideration of a surgical abdomen and the exam remained normal. There was also no endometritis as the patient was not delivered. There was no uterine tenderness or suspicion of amnionitis. There was no abdominal guarding or rebound to suggest peritonitis. There was no pelvic abscess on ultrasound imaging. There was no physical exam or suspicion of peritonitis given the normal abdominal exams. Thus, no criteria were met for inpatient admission in this case of pelvic infection. In this setting, IV antibiotics can be provided and the patient discharged to home. In this case, after a review of the medical records and these care guidelines, there was no medical necessity for admission to acute inpatient care. The peer reviewed literature allows for these patients to be managed at a lower level care. Patients without acute signs of sepsis, fever, hypotension or concerns for atypical infection or failure of prior treatment, can be managed at a lower level of care.