Diagnosis: Urinary Tract Infection; Gastritis.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This female patient has with a history of marijuana use, multiple sclerosis (MS), and urinary incontinence who presented to Emergency Department (ED) with complaints of abdominal pain, diarrhea for one day. In the ED, the patient's white blood count and heart rate were increased, urinalysis revealed leukocyte and bacteria. The patient was given Keflex and Toradol injection in ED, and admitted with diagnosis of urinary tract infection (UTI) and gastroenteritis. The patient was given intravenous (IV) fluids, IV Rocephin, and was tested for clostridium difficile. Psychiatry consult recommended Lexapro. The patient had no suicidal ideations. She was transitioned to oral antibiotics. The patient improved and was discharged in stable condition to a facility.

The insurer denied coverage for the inpatient hospital admission as not medically necessary and noted that the patient presented to the hospital because there was no one to care for her at home. The insurer noted a lack of fever or unstable blood pressure, or decline in kidney failure. The patient was taking Tecfidera for her multiple sclerosis, but stopped several months prior due to lack of access to medical care.

Per MCG Health Guidelines for UTI Rapid Review Guidelines (RRG), this patient's clinical presentation fails to meet the clinical indications for admission to inpatient care. As per MCG Health guidelines for Urologic Disease General Recovery Guidelines (GRG), this patient's clinical presentation fails to meet the clinical indications for admission to inpatient care.

Based on the review of the medical record and literature above, the inpatient hospital admission is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.