UTI 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 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.

A 62-year-old female has requested coverage for past urgent care services provided. Findings: The physician reviewer found that the patient presented to an urgent care facility complaining of pain in her lower abdomen, burning pain with urination, and visible blood in her urine. Her symptoms had begun the previous day. Her vital signs were normal. The patient rated her pain at 8 out of 10 on the pain scale. Upon evaluation, the patient’s history did not include fever, flank pain, nausea, vomiting or diarrhea; however, a previous history of kidney disease was noted. Physical examination revealed suprapubic pain to palpation. Urinalysis was positive for leukocyte esterase and blood, findings most compatible with acute hemorrhagic cystitis - a urinary tract infection (UTI).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A review of the record indicates that the enrollee presented to an urgent care center. The records noted a two-day intermittent fever, night sweats, and right flank pain. The enrollee was evaluated, laboratory evaluations were completed, and she was discharged home with medication therapy including an antibiotic and an anti-inflammatory. The providers assessment was pyelonephritis with tubule-interstitial nephritis.At issue in this case is whether the enrollee received emergency medical services on the date of service in question.

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.

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 uti, then check the rights and deadlines that apply to your plan.