Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract infection.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female whose inpatient hospital admission is under review. The patient has a history of recurrent UTI (urinary tract infection), VRE (vancomycin-resistant enterococcus), ketamine abuse who presented with  abdominal pain. The patient had several days with dysuria, and pain with intercourse.
The patient's vitals are as follows:
Temperature- 98.1.   Pulse-111  Blood Pressure- 168/126.   Respiratory rate-18
General : Ill appearing, not diaphoretic
CVS (cardiovascular system): Normal
Lungs: Normal
Abdominal: soft, epigastric tenderness, no tenderness/guarding RLQ (right lower quadrant). No costovertebral angle or flank tenderness.

White blood cells 11.5 (high)
Hemoglobin - 8.2 (low)
Hematocrit - 24.5 (low)
Platelet- 467 (high)
Sodium - 134
Potassium- 5.1
Chlorine clearance- 112
Carbon dioxide- 12 (low)
Blood urea nitrogen- 25 (high)
Creatinine- 2.3 (high)
Uric acid- mod epi, 25-50 white blood cells, mod LE
Urine culture- .K. pneumoniae, R ampicillin, R tetracycline

Computed tomography abdominal/pelvis without contrast noted:
1) Persistent B hydronephrosis and hydroureter
2) Persistent abnormal parenchymal density B kidney (can not rule out acute pyelonephritis or abscess)
3) Urinary bladder thickening
4) No urinary calculus
5) Mildly distended gallbladder
6) Mild hepatomegaly.

In the ER (emergency room), the patient was though to have UTI (urinary tract infection) with a multi-drug resistant organism, and acute renal failure. She was started on IV (intravenous) linezolid, admitted, and ID (infectious disease) consult obtained, who switched antibiotics to IV (intravenous) Meropenem. Patient improved after a few days and discharged home on oral antibiotics.

Yes, the inpatient hospital admission was "medically necessary."
This patient did not have an uncomplicated UTI (urinary tract infection) or pyelonephritis and thus would not meet criteria for outpatient treatment and oral antibiotics listed in the IDSA  (Infectious Diseases Society of America) guidelines (1). This patient had a complicated urinary history, with chronic elevated creatinine and hydronephrosis, as well as MDR (multiple drug resistance) organisms. She presented with a complicated UTO (urinary tract obstruction) associated with renal failure and sepsis. Standard of care would require admission for the following reasons:
1) IV (intravenous) antibiotics for potential MDR (multiple drug resistance) organism
2) UTI (urinary tract infection) in setting of acute renal failure
3) Sepsis in setting of Complicated UTI (urinary tract infection) and renal failure
4) Continued substance abuse in the setting of organ failure necessitating psych consult.

The above points were considered in the treating provider's appeal, but not found or referenced in the insurance company denial letter, which contained a list of individual criteria without considering the entire clinical scenario.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Failure to admit and treat the patient could lead to organ damage, organ failure, septic shock, or death.