Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Genitourinary/Kidney Disorder - Urinary Tract Infection (UTI).
Treatment: Inpatient Hospital.
The insurer denied Inpatient Admission.
The denial is overturned in part. 

The patient is a female that was admitted. She had a past medical history of asthma, major depressive disorder (MDD), bipolar disorder, left (L) ovarian cyst status/post (s/p) cystectomy and multiple urinary tract infections. She presented initially to an outside emergency department (ED) with back pain on left side radiating to left abdomen and increased urinary frequency and urgency. She was diagnosed with a urinary tract infection (UTI) and given a dose of Diflucan for white discharge noted on gynecological (GYN) exam, and prescription of Macrobid. As per clinical documentation, the patient took antibiotics as prescribed without improvement in dysuria or urinary frequency in the following 2 days. At work, her back pain and dizziness worsened, and an ambulance was called. In the ED, the patient was noted to have a fever up to 101.4. Physical exam findings showed dry mucous membranes, tachycardia, left costovertebral angle (CVA) tenderness, and mild tenderness in the left lower abdomen as well as suprapubic area.
She was given intravenous (IV) Ceftriaxone, Tylenol for fever, and normal saline bolus followed by maintenance fluids of dextrose (D5) normal saline (NS). The patient was admitted for acute pyelonephritis and failed outpatient treatment. Her hospital course was unremarkable and remained hemodynamically stable throughout admission. She had a renal bladder ultrasound which was normal. On her second day of admission, her symptoms of headache, dizziness, and back pain had resolved. She was tolerating by mouth (PO). The patient was discharged on Ciprofloxacin the following day.
At issue is the medical necessity of the Inpatient Admission.

The health plan determination of medical necessity is overturned in part.

The requested health service/treatment of Inpatient Admission is medically necessary for this patient in part.
As per the Clinical manual of Emergency Pediatrics, indications of admission for UTI/Pyelonephritis are in patients that are toxic appearing (high fever, flank pain), dehydrated, unable to tolerate oral intake, or a febrile patient with risk for decreased renal function such as single kidney or decreased glomerular filtration rate (GFR). This patient presented to the ED with fever and flank pain, and physical exam findings were concerning for dehydration. This member presented to the ED with fever and flank pain, and physical exam findings concerning for dehydration. However, there was no history or clinical documentation of poor PO, or vomiting, the physical exam findings did not show that patient was toxic appearing, or hemodynamically unstable. The patient was tachycardic and febrile, which resolved with the use of Tylenol. Her labs did not show any concern for decreased GFR or concerning kidney function. However, she did have flank pain and fever, coupled with a 2-day history of failed outpatient treatment. Therefore, it was prudent for admission for IV antibiotics. It has been shown that a short course of IV therapy for pyelonephritis followed by oral therapy is effective.
Therefore, admission was medically necessary in part, once the patient was able to tolerate PO, and was clinically stable, she could have safely and appropriately received treatment (PO antibiotics) at this facility at the observation level of care awaiting sensitivities, or subsequent transition to outpatient care, rather than continued admission at an inpatient level of care.
Therefore, the requested health service/treatment of Inpatient Admission is medically necessary for this patient in part.