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201906-118425

2019

Fidelis Care New York

Medicaid

Infectious Disease

Inpatient Hospital

Medical necessity

Overturned

Case Summary

The patient has a history of hypertension and asthma who presented to the hospital with body aches, fever and nausea. The patient reported feeling extremely fatigued. The patient denied neck stiffness, rash, recent travel and diarrhea. The patient was admitted with urinary tract infection and suspected acute coronary syndrome (ACS). The plan of care included urine cultures, intravenous (IV) antibiotics, cardiac enzymes, EKG, chest computed tomography (CT), echocardiogram, and continue other home medications.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient had sepsis in the setting of urinary tract infection versus pyelonephritis and she had significant fevers and positive urine cultures. In addition, she did objectively meet sepsis criteria based on heart rate and white blood cell count along with positive cultures. She was at increased risk for an adverse outcome.

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