Diagnosis: Hematuria and abdominal pain Treatment: Inpatient admission The insurer denied the inpatient admission The denial is overturned. The patient is a male without significant past medical history who was admitted with hematuria and abdominal pain. Computed tomography of the abdomen/pelvis demonstrated mild to moderate bilateral hydroureteronephrosis and bilateral perinephric stranding. The patient was afebrile with a blood pressure 173/95 pulse 94. Labs were notable for white blood cell count 20,800, glucose 188, potassium 5.1, bicarbonate 19, BUN (blood urea nitrogen) 146, and creatinine 7.1. The urinalysis was positive for leukocyte esterase, bacteria, and white blood cells. Intravenous fluids intravenous antibiotics were provided. A Foley catheter was placed. Serial glucose levels were followed and sliding scale insulin was administered. The creatinine on follow-up was 3.0, 2.3, 1.7, and 2.6. Amlodipine and glipizide were initiated. The urine culture was negative. The patient was discharged on tamsulosin and finasteride. The member had severe acute kidney injury on admission with a BUN 146 and creatinine 7.1, with no preceding history of chronic kidney disease. This was accompanied by hyperkalemia and metabolic acidosis. Renal function improved initially with the creatinine dropped to 1.7 mg/dL but subsequently worsened with a rise in creatinine to 2.6. The member additionally was newly diagnosed with diabetes, indicating he was in immunocompromised state. He had bilateral pyelonephritis noted on computed tomography of the abdomen/pelvis with evidence of urinary obstruction on admission, and with a significant degree of leukocytosis. Intravenous antibiotics and intravenous fluids were required. In summary, inpatient admission was medically necessary.

1) Harrison's Principles of Internal Medicine, 20th edition 2) MCG (Milliman Care Guidelines), 24th edition, ORG M-326, Renal Failure, Acute 3) MCG (Milliman Care Guidelines), 24th edition, ORG M-300, Urinary Tract Infection