Diagnosis: urinary tract infection
Treatment: inpatient stay

The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a female with a history of diabetes mellitus (DM), hypertension (HTN), and recurrent urinary tract infection (UTI) who presented with fevers, dysuria, urinary frequency and flank pain for two days duration. She denied cough, chest pain, shortness of breath, headache, neck stiffness of ear pain. Her vitals showed that she was afebrile with a pulse of 127, a blood pressure of 181/105, a respiratory rate of 16, and a room air pulse oximetry of 99%. On exam, she was not in any acute distress and she had left sided costovertebral angle tenderness.

The inpatient admission was medically necessary based on the documentation provided. The patient presented with suspected pyelonephritis in the setting known severe left hydronephrosis/hydroureter. A complicated urinary tract infection in the setting of significant uropathy is an indication for an inpatient admission based on Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 26th urinary tract infection guidelines. In addition, she also had hyperglycemia and evidence of poorly controlled diabetes which placed her at further increased risk of complication and a poor outcome without appropriate management. Admission to an inpatient setting with close monitoring, IV antibiotics and urologic consultation was appropriate and necessary in this case.