Diagnosis: Urinary tract infection.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult with past medical history significant for recurrent urinary tract infection (UTI), multidrug resistant (MDR) organism, multiple sclerosis, neurogenic bladder, and right lower extremity deep vein thrombosis who presented to the emergency department with complaints of UTI symptoms.

Vitals on presentation included: Temperature 36.7 degrees Celsius, Blood Pressure 117/83, Pulse 90, Respiratory Rate 18, oxygen (O2) saturation 97%. Laboratory results included the following: white blood cell count (WBC) 3.7, Hemoglobin-13.1, Hematocrit-38.6, creatinine-0.9, glucose-94.

Patient was started on intravenous (IV) fluids and empiric antibiotics (linezolid and meropenem) for possible UTI. Computed tomography (CT) scan of abdomen/pelvis showed no evidence of pyelonephritis or cystitis. Blood cultures were negative and urine culture showed multiple organism suggestive of possible contamination. Patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient follow-up.

According to documentation, patient was admitted for possible recurrent UTI. Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory findings including normal white blood count (WBC). Additionally, CT scan was negative for cystitis and pyelonephritis. Based on above findings, patient met criteria for observation level of management.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for inpatient site of service is not substantiated.