
201912-124316
2020
Empire Healthchoice Assurance Inc.
Indemnity
Genitourinary/ Kidney Disorder
Inpatient Hospital
Medical necessity
Overturned
Case Summary
Diagnosis: Urinary tract infection
Treatment: Inpatient admission
The inpatient admission was medically necessary.
The patient is a female whose inpatient admission is under review. The patient was diagnosed with a urinary tract infection (UTI) three days prior to the current emergency room (ER) visit, and was placed on Bactrim. The patient failed to improve and developed fever, nausea, and left greater than right (L>R) flank pain.
Examination revealed the following:
Temperature (T) - 101.8
Pulse (P) - 99
Blood pressure (BP) - 131/95
Respiratory rate (RR) - 16
General - no acute distress (NAD)
Chest - normal
Cardiovascular system (CVS) - normal
Abdomen - normal
Back - bilateral flank tenderness
Labs revealed the following"
White blood cells (WBC) - 11.61 (high)
Hemoglobin (Hg) - 11.9
Hematocrit (HCT) - 35.7
Platelets (PLT) - 303
Sodium (Na) - 138
Potassium (K) - 3.9
Chloride (Cl-) - 106
Carbon dioxide (CO2) - 21
Blood urea nitrogen (BUN) - 10
Creatinine - 0.94
Urine analysis (UA) revealed WBC 0-5 and 0-3 red blood cells (RBC). The patient's abdominal ultrasound (U/S) was normal.
In the ER, the patient was thought to have failure of outpatient antibiotics, was started on intravenous (IV) ceftriaxone, and was admitted for pyelonephritis. She was given IV morphine for pain control. The patient improved, urine culture came back as contaminated, and she was sent home on oral (PO) ciprofloxacin.
Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). In this patient, the patient failed outpatient treatment and had fever and leucocytosis and severe pain in spite of three days of therapy, thus not a candidate for outpatient therapy. Standard of care would dictate admitting such a patient, ruling out renal abscess and antibiotic-resistant bacteria. Thus, this admission was warranted, supported by standard of care and the Infectious Diseases Society of America (IDSA) guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.