Urinary Tract Infection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings: The physician reviewer found that The patient who presented to the emergency department after being notified of a positive blood culture. The patient received a call from the emergency department advising him to go to the hospital immediately. Of note, the patient was seen the day before for fever, generalized weakness and urinary symptoms. He was found to have a urinary tract infection and laboratory testing was performed. He returned to the emergency department for re-revaluation due to blood cultures noted to be growing gram negative rods. The patient reported persistent fever. His abdomen was soft and non-tender. Laboratory data was significant for a white blood cell count. Intravenous (IV) Rocephin was administered.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings: The physician reviewer found that the patient presented with complaints of dizziness, tremors, nausea, shortness of breath and vomiting. She reported five episodes of emesis. Her symptoms began that morning and progressed to the point where she was feeling unsteady on her feet and shaky. The patient reported her dizziness made ambulation difficult. She denied chest pain, headache or fevers. She denied vertigo or hearing loss. Her past medical history included diabetes. The patient’s initial vital signs revealed a pulse of 90, respirations of 20, blood pressure of 161/90, and an oxygen saturation of 99% on room air. The patient appeared tremulous. Heart sounds were regular without murmurs. Respirations were non-labored.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services on an emergent or urgent basis. Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with mild abdominal pain with dysuria and hematuria. The patient denied fevers, vomiting, or other systemic symptoms. Her vital signs were normal and she was not in acute distress. Based on the patient’s presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a multianalyte assay with algorithmic analysis. In this case, the records do not establish a documented history of recurrent or refractory vaginitis. The patient’s primary symptoms were consistent with a urinary tract infection, which was treated appropriately. Additionally, according to the American College of Obstetricians and Gynecologists, the clinical utility of multianalyte assay and polymerase chain reaction testing continues to be evaluated.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving urinary tract infection, then check the rights and deadlines that apply to your plan.