Diagnosis: Acute pyelonephritis

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission. The denial is reversed.

The patient is a female child with a history of obesity who presented to the Emergency Department (ED) with complaints of severe headache both sides of her head, photophobia, fever, nausea, vomiting, dysuria, abdominal pain and other constitutional symptoms. The patient was febrile at 102.8, had a heart rate of 109 bpm, and pain score of 10 out of 10 in severity. The patient was initially ill-appearing although not toxic, and her neck was supple although it was tender to palpation. The patient's differential diagnoses included pyelonephritis, migraine, meningitis and idiopathic intracranial hypertension. The patient's lab results were markedly abnormal for leukocytosis and pronounced left shift (bandemia of 18%). The patient's urinalysis was abnormal indicating urinary tract infection (UTI) and was with ketones indicating dehydration.

Although this patient's ultimate diagnosis was acute pyelonephritis due to E. coli infection, the ED's medical decision making was appropriate in considering this patient's possible diagnosis of meningitis. The patient's lumbar puncture (LP) attempt was unsuccessful and needed to be done under interventional radiology (IR) guidance. Pending the LP, the patient required and received intravenous (IV) ceftriaxone. Besides ruling out meningitis, an LP was important to perform for the opening pressure, as this patient was at risk for idiopathic intracranial hypertension given her body habitus and age. Literature supports that intracranial hypertension if not managed urgently could lead to blindness. This, based on this patient's clinical presentation at the time of admission, inpatient admission was medically necessary to safely treat and monitor this patient's medical condition.

The health care plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission should be reversed. The medical necessity is substantiated.