Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pain.
Treatment:  Inpatient Stay.
The insurer denied the Inpatient Stay.  The determination is upheld.

The patient has a medical history of diverticulosis complicated by diverticulitis last reported 8 years prior, anxiety, and depression.  She presented to the emergency department with severe acute abdominal pain, nausea, one episode of vomiting, two episodes of diarrhea, chills, and dysuria.  She had a colonoscopy 2 weeks prior.  Lab results showed white blood cell count of 11.2 thousand per cubic milliliter (K/uL) and lactic acid of 3.8 millimoles per liter (mmol/L).  A computed tomography scan of the abdomen and pelvis showed recurrent moderate proximal sigmoid fecal retention, with probable superimposed stercoral colitis identified, without pneumatosis; multiple hepatic and renal cysts; extensive sigmoid diverticulosis without obvious acute diverticulitis, microperforation, or pericolic fluid.  Physical examination was notable for left lower quadrant tenderness to palpation.  She was made nil per os and treated with intravenous fluids, morphine, ciprofloxacin, metronidazole, and proton pump inhibitor.  A gastroenterology consultation noted cramping lower abdominal discomfort in the setting of a recent colonoscopy and moderate diverticulosis, with imaging findings, which may represent mild acute diverticulitis or stercoral colitis; her bowel movements may represent leakage around formed stool if indeed more proximal stool impaction; the recommendation was to continue intravenous antibiotics, nil per os (NPO), and await surgery input.

A general surgery consultation concluded that the patient had colitis and dehydration, and a benign abdominal exam, but no definitive evidence of diverticulitis; the recommendation was for intravenous hydration, further colitis workup, and no surgical intervention.  She reported a low-grade fever the night before, slight improvement in abdominal pain, and resolution of nausea, but denied fever and chills; she reported a small bowel movement.  Physical examination was notable for distended abdomen.  Lab results showed an elevated white blood cell count of 14.0 K/uL and normalized lactic acid.  She was transitioned to oral tramadol.  She had no acute distress and noted constipation despite stool softener and laxatives, improvement of lower abdominal pain, and vomiting and watery bowel movements.  Labs showed lower white blood cell count of 10.0 K/uL.  Her diet was advanced to clear liquids and a Dulcolax suppository and Miralax were given for constipation.  She had improved abdominal pain, and loose bowel movements the prior day; her abdomen was still distended.  She was discharged on Miralax, docusate, ciprofloxacin, and metronidazole, with a plan for gastroenterology follow-up.  At issue is the medical necessity for an inpatient stay.

The inpatient stay was not medically necessary.

In patients with uncomplicated diverticulitis (without complications such as abscess or perforation) outpatient management or observation is the standard of care [1].  The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2].  A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the Emergency Department and then discharged with oral antibiotics [3].  A systematic review of the literature underscored this [4].  A lower level of care can be appropriate over outpatient care when there is persistent infection, as in this case with leukocytosis [5].  However, there was no protracted fever or hypotension to suggest that antibiotics were ineffective.  There had been no evidence of abscess on imaging [4-6].  The patient improved on intravenous antibiotics and was discharged on oral antibiotics.  Additionally, stercoral ulcer and colitis were considered, but the patient ultimately had bowel movements, and there was no concern for bowel obstruction, perforation, or other complications [7,8].  No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented.  For these reasons, the inpatient level of care is not supported as medically necessary in this case.

Per the Milliman Care Guidelines for Gastroenteritis, inpatient admission is not medically necessary, as the patient did not have a suspected severe infection (eg, bloody diarrhea), severe abdominal tenderness, toxic megacolon, hemodynamic instability, vomiting that is severe or persistent, dehydration that is severe or persistent, hemolytic uremic syndrome, inability to maintain oral hydration (eg, needs intravenous (IV) fluid support) that persists after emergency department and observation care treatment, parenteral nutrition regimen that must be implemented on inpatient basis, other condition, treatment, or monitoring requiring inpatient admission.