Endocrine/metabolic/nutritional
Inpatient hospital

This case involves a female sent into the emergency room by her primary care physician because of fevers and low blood pressures in the office. The fevers started the day before; she has been taking ibuprofen with good relief. Unfortunately, she woke up again on the day of admission with subjective fever and went to see her primary care physician. Upon arrival in the emergency department, she is afebrile with a temperature of 97, tachycardic at 103, with respirations of 20. Blood pressure was 92/68. On physical exam, she is tachycardic, lungs are clear, abdomen is soft, and there are no rashes. Under review is the inpatient level of care.

The health plan's determination is upheld. The inpatient hospital stay is not medically necessary for this patient. This is a young and healthy patient who comes in with a fever and dehydration, and history of prior urinary tract infections treated with Keflex. On arrival, she is afebrile, borderline tachycardic, and responded to the treatment of IV fluids. She does not have evidence of severe sepsis or septic shock. Lactate is normal. White blood cell count is normal. She only has 40 white blood cells on the urinalysis and has a CT scan without abnormalities. There is no evidence of organ dysfunction. Within 24 hours, vital signs are stabilized; she is no longer exhibiting tachycardia or low blood pressure as would be expected in a young individual. She does not have the typical symptoms of sepsis related to pyelonephritis; she does not appear bacteremic, although the cultures were only 24 hours out. This type of presentation can be managed at a lower level of care. This patient appropriately responded to treatment with IV fluids and broad-spectrum antibiotics. In conclusion, the inpatient hospital stay is not medically necessary.