Diagnosis: Abdominal pain.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a young adult female with history of renal calculi who presented to the emergency department for evaluation of abdominal pain for 5 days with nausea. Patient was febrile and tachycardic in emergency room, computed tomography (CT) revealed right upper pole anterior poorly defined hypodense renal abscess (new), felt to be possible complicated cyst or early abscess. Patient admitted for intravenous antibiotic treatment, consults with Urology, Infectious Disease, Gynecology, diagnosis of complicated pyelonephritis. Patient improved on intravenous (IV) Levaquin, then on day 2 she was transitioned to oral Levaquin. She was stable for discharge with outpatient follow up.

Per Milliman Care Guidelines (MCG) Health (26th) Urinary Tract Infection, the patient fails to meet clinical indications for admission to inpatient care. There was no evidence of hemodynamic instability, altered mental status that is severe or persistent, pregnancy, persistence or worsening of clinical findings despite observation care, ureteral obstruction, renal or perinephric abscess.

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 the inpatient admission is not substantiated.