Diagnosis: Flank pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a male with a past medical history remarkable for depression bipolar disorder, chronic knee pain, and nephrolithiasis, who was admitted for reports of right flank pain. Review of system was positive for foul smelling urine, nausea, vomiting, back pain, runny nose and sore throat.
The patient was afebrile (Temperature of 37.2) and described as comfortable. His blood pressure was 120/82, pulse rate of 97, respiratory rate of 19, and oxygen saturation of 95% (percent) on room air. Physical examination was remarkable for right costovertebral angle (CVA) tenderness.
Laboratory evaluation demonstrated a sodium of 146, potassium 4.4, chloride of 109, carbon dioxide (CO2) of 24, blood urea nitrogen (BUN) of 19, creatinine of 1.19, glucose of 77, white blood cell count (WBC) of 10.3, Hb (hemoglobin) of 10.3, Hematocrit (HCT) of 32.8, and platelet of 323. Renal ultrasound revealed right ureteral stent in place without hydronephrosis, nonobstructive stone in the lower pole of the right kidney, and findings suggestive of bilateral upper urinary tract infections. The patient was admitted for right flank pain consistent with non-obstructing kidney stone and pyelonephritis.

The requested inpatient hospital admission was medically necessary for this patient.
The patient was admitted for acute pyelonephritis with non-obstructing renal stone in the setting of intractable pain resistant to pain medications. Additionally, the patient had a urinary tract infection with E. coli that was resistant to many oral medications. As such, intravenous broad-spectrum antibiotics were required. The patient also required IV (intravenous) pain medications for persistent pain due to renal colic.
Urinary Tract Infections (UTIs) can be divided into lower and upper tract infections. Lower tract infections involve the bladder (cystitis) and urethra (urethritis). UTIs can be further categorized as simple or complicated. Simple UTIs, also referred to as uncomplicated UTIs, occur in young, healthy, nonpregnant women with normal anatomy. Complicated UTIs are associated with involvement of the upper urinary tract; and can be caused by drug-resistant organisms and are more likely to require long antibiotic courses or parenteral antibiotics. Patients with features consistent with systemic inflammatory response syndrome such as fever, elevated white blood cell count and positive blood cultures can be associated with multi-organ dysfunction, hypo-perfusion or hypotension. The Infectious Diseases Society of America (IDSA) recommends that urine cultures with susceptibility testing be obtained for all patients with acute pyelonephritis. Additionally, the antimicrobial choice should be reassessed once culture results become available, usually within 48 to 72 hours to assess for improvement in clinical status. Elderly patients with UTIs are also at increased risk for serious complications and mortality.