Diagnosis: Urinary Tract Infection
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

The patient was a teenage female admitted on for frequent urination. Urine analysis was consistent with urinary tract infection (UTI) and was started on intravenous (IV) antibiotics. The patient was also found to have elevated creatinine secondary to prerenal azotemia and was started on IV fluid. Creatinine improved and patient was discharged in stable condition the next day.

The patient was admitted for UTI and her condition responded to standard therapy in 24 hours. The patient remained hemodynamically stable without complications and discharged in stable condition. Per evidence-based literature, observation level of care is appropriate to treat this patient's condition.

A multiyear database analysis including a nationally weighted sample of over 1.9 million pediatric patients presenting to an Emergency Department (ED) with a UTI (urinary tract infection) found an admission rate of 25% (percent) for infants younger than 1 year, 3% (percent) for patients 1 to 5 years of age, 2% (percent) for patients 6 to 13 years of age, and 12% (percent) for those 14 to 17 years of age [1].

A multicenter study including 350 children presenting to an Emergency Department with a first febrile UTI found that 25% (percent) were admitted for inpatient care.[2]

Implementation of a day treatment center protocol for infants with a febrile urinary tract infection led to 57% (percent) of patients being given a trial of IV (intravenous) and oral antibiotics on an outpatient basis, with 88% (percent) of these infants avoiding hospital admission [3].

When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, there were no requirements for inpatient level of care. Observation was more appropriate.

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.