Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sigmoid Diverticulitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

According to the medical records, the patient presented in the emergency department (ED) with fever, chills, rigors, dizziness, nausea, and left lower quadrant abdominal pain. The patient endorsed intermittent dizziness and abdominal pain that started two weeks before admission. In the ED, the physical exam was remarkable for tachycardia and tenderness to palpation in the lower abdomen under the umbilicus and to the left lower quadrant. A code Sepsis was activated, and intravenous (IV) normal saline (NS) bolus was administered immediately (stat). Significant labs included a white blood cell (WBC) count of 14.9, neutrophils 91.7, absolute neutrophil count (ANC) 13.7, lymphocytes 3.2, glucose 107, chloride (Cl) 110, carbon dioxide (CO2) 21.7, and lactate 2.57. A urinalysis (UA) noted bacteria. An electrocardiogram (EKG) showed sinus tachycardia at 102 beats per minute (bpm), as well as a nonspecific T wave abnormality. 

The surgery consult recommended computed tomography (CT) of the abdomen/pelvis (A/P). The CT A/P revealed sigmoid diverticulitis hepatic steatosis and disc space narrowing at lumbar (L)4-5. Additional treatment included Zosyn 3.375 milligrams (mg) intravenous (IV) piggyback (PB), Vancomycin 1-gram (Gm) IVPB, and Zofran IV push (P). Additional labs included procalcitonin 3.77, glucose 112, Cl 110, CO2 18.7, total bilirubin (T Bili) 1.4, WBC 9.6, neutrophils 86.4 and ANC 8.3. Per the surgery follow-up, the CT scan was consistent with uncomplicated diverticulitis. The patient improved with bowel rest and IV antibiotics. The patient was voiding, and tachycardia was resolved. The patient was cleared for discharge to home on a two-week course of Augmentin and Bacid. The patient was advised to follow up with their primary medical doctor within one week.

The Milliman Care Guideline (MCG) indicates Inpatient care admission is indicated for 1 or more of the following: Hemodynamic instability, Bacteremia, Hypoxemia, altered mental status that is severe or persistent, new coagulopathy (e.g., reduced platelet counts consistent with disseminated intravascular coagulation), Tachypnea that persists despite observation care, Dehydration that is severe or persistent Inability to maintain oral hydration (e.g., needs IV fluid support) that persists after observation care, Evidence of end organ dysfunction (e.g., rising creatinine, myocardial ischemia, rising liver function tests) that is severe or persists despite observation care, Core (rectal) temperature lower than 95 degrees Fahrenheit (F) (35 degrees Celsius [C]) (e.g., thought to be due to infection), Parenteral antimicrobial regimen that must be implemented on inpatient basis (e.g., infusion or monitoring needs beyond capabilities of outpatient parenteral therapy), Isolation indicated that cannot be performed outside hospital setting.  

Based on the patient's clinical manifestations and the cited guidelines, the patient's needs could have been safely provided at a lower level such as in an observation care unit. Therefore, inpatient hospital admission is not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a full hospital admission is not substantiated.