Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis, UTI.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is partially overturned.

This is a female patient with a history of tick-related encephalitis with multiple complications. She was on lamotrigine, topiramate, weekly Bicillin, Valium, Zyprexa, and Seroquel. She was receiving plasmapheresis and intravenous immunoglobulin (IVIG) through a central line. She had a recent admission for an extended spectrum beta-lactamases (ESBL) urinary tract infection, and had been sent home on cefdinir. She had a new subclavian port placed recently. He caregivers were directed by her urologist to bring her to the emergency department for a fever, the day prior, she had finished the cefdinir and undergone a urodynamic study at which time an in-dwelling Foley catheter was removed.
In the emergency department (ED), the patient's temperature was 40.4 degrees Celsius (C) with a borderline low blood pressure. She was chronically ill appearing with a nasogastric (NG) tube in place and a right subclavian port. She was well perfused and did not have a rash. Her urine showed greater than 50 white blood cells (WBCs) and large leukocyte esterase. The white blood cell count (WBC) was 10.1 with 81 percent (%) neutrophils. The metabolic panel was normal. The C-reactive protein (CRP) was 0.85. She was thought to have possible urosepsis, and in the emergency department (ED), she was given ceftriaxone and vancomycin and admitted for further management with a new Foley catheter in place.
On arrival to the hospital floor, she appeared the same. There was additional concern for a line infection in addition to urinary tract infection, and she was started on broad spectrum antibiotics-ceftriaxone, vancomycin, and meropenem. Urology and infectious disease services consulted. She was still febrile to 39.3 degrees Celsius. Thereafter, she was afebrile. The urine culture was growing gram negative rods;the pathogen was identified as pseudomonas and the blood culture was no growth at 48 hours. She remained in the hospital. At issue is the medically necessary of an inpatient stay.

The first two days of the stay were medically necessary for acute inpatient care. The third day was not medically necessary for an acute inpatient level of care; the patient could have been discharged that day.
Initially, inpatient hospitalization was medically necessary to treat possible urosepsis or a bloodstream infection from the central line. She was a high risk, debilitated patient with frequent urinary tract infections. She just had a Foley catheter in place, which was a risk for a urinary tract infection (UTI), and also just had urodynamics done, which is a separate risk for UTI. She had a high fever on presentation and a borderline blood pressure. Given the multiple possible reasons for sepsis, she required admission to provide broad spectrum parenteral antibiotics until the caregivers could be reasonably sure she did not have sepsis/bacteremia. This took two days.
By the third day, the patient had been afebrile for more than 48 hours, the blood culture had been negative for more than 48 hours, and the urine pathogen was known to be pseudomonas. She did not appear ill and had normal vital signs. Further treatment of this urinary tract infection could have been accomplished as an outpatient.