Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute diverticulitis.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is the case of a female with past medical history of Hashimoto's and abdominal pain who presented to the Emergency Department (ED) with the diagnosis of complicated diverticulitis. The patient complained of a 2-day history of severe middle and left lower quadrant (LLQ) abdominal pain. She says it was worse with movement and she could barely walk due to pain. She denied fever, nausea or vomiting. She had a colonoscopy in in the past which showed diverticulosis without any other abnormalities. As per the triage note that patient complained of abdominal pain 8/10 with a temperature of 99.3. In the ED she was afebrile with normal vital signs. Labs were significant for white blood cell (WBC) count 11.6. Lipase was normal. Liver enzymes were normal. Computed tomography (CT) of the abdomen showed sigmoid diverticulitis with a localized perforation. There was no distant free air or abscess. Exam revealed the abdomen to be soft, tender to palpation in middle and left lower quadrant. There was no rebound or guarding. The patient was admitted for contained perforated diverticulitis and the patient was admitted to floor, with orders for intravenous (IV) antibiotics, nothing by mouth (NPO), IV fluids, and pain control as appropriate. 

At issue here is the insurer has denied coverage for the inpatient as not medically necessary. The plans clinical criteria considers a full hospital admission for bowel problems medically necessary when surgery is needed right away or other severe problems exist. These might include severe pain, vomiting or high fever. The decision was based on Milliman Care Guidelines (MCG) guideline, Diverticulitis, acute (ORG: M-150).

The hospital is appealing and noted that admission was indicated for peritoneal signs, inability to maintain oral hydration. Inpatient stay was warranted as this patient presented to the ED with contained perforated diverticulitis with persistent abdominal pain, and difficulty ambulating necessitating NPO, IV fluids, IV antibiotics and monitoring.

As shown in the chart the patient had acute diverticulitis with a contained perforation seen on CT -thus designating this as a complicated acute diverticulitis. The patient needed to be kept NPO and to be given IV antibiotics. Although she did not appear to be septic, she did have LLQ pain and an elevated WBC with a shift to the left. The patient met criteria according to MCG 26th Edition Diverticulitis, Acute ORG: M-150 due to the finding of a perforation which was contained on presentation requiring NPO and IV antibiotics. They needed to follow the patient to make sure that she improved. Once she improved, she was able to be discharged. MCG also noted that goal length of stay is 2 days. MCG further noted that acute diverticulitis may be uncomplicated or complicated. 
Finally, MCG also noted that a "systematic review of 6 studies (479 patients) with perforated diverticulitis without generalized peritonitis reported 85% successfully treated with nonoperative management (e.g., bowel rest, as needed antibiotics and percutaneous drainage). Thus, this patient required inpatient stay. In this case the patient had complicated acute diverticulitis given the finding on CT of the abdomen and therefore did not qualify to be treated as an outpatient/observation. Thus, in this case the physicians were correct and acted prudently in the hospitalization of this patient and in maintaining acute care and observation with IV antibiotics. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.