Diagnosis: Elevated Blood Pressure and Painless Hematuria.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with chronic kidney disease in the setting of polycystic kidney disease and hypertension. She presented to the hospital with hematuria in the setting of medication non-compliance and uncontrolled hypertension.

Patient was admitted and started on fluid and antibiotics. Urine culture was significant for Citrobacter, and the patient was transitioned to oral antibiotics.

The health plan denied coverage of the inpatient admission, as there was no documentation that the patient could not have been safely and effectively managed at a lower level of care. The decision is being appealed.

No, the Inpatient admission was not medically necessary.
The inpatient admission was not consistent with generally accepted national standards of medical practice. It cannot be established that it was not provided primarily for the convenience of the patient or the practitioner, or that it was the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Based on the available data, inpatient level of care was not medically necessary, as there was no documentation regarding Hemodynamic instability, Vomiting that was severe or persistent, Altered mental status that was severe or persistent, Persistence or worsening of clinical findings despite observation care treatment, Parenteral antibiotics needed beyond observation care treatment, Pregnancy of 24 weeks' gestation or beyond, Immunocompromised state, New coagulopathy, Urinary system finding that required invasive procedure, or placed patient at increased risk for systemic illness or delayed recovery, Acute renal failure or need for IV (intravenous) hydration support or Other condition, treatment, or monitoring requiring inpatient admission. Based on available data these criteria are not met. Therefore the inpatient admission was not medically necessary.