Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Diverticulitis
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is overturned.

The patient is a female who was admitted to the hospital for bloody stools and left lower quadrant pain for five days. She self-administered Cipro for five days before arrival for her abdominal pain and only decided to come to be evaluated when she developed rectal bleeding. She denied any fevers or chills. There was no vomiting. The patient's temperature was 99.1, heart rate 101, and her blood pressure was 139/76. The patient was well-appearing upon the examination, fully oriented, with a soft nondistended abdomen. She had some left lower quadrant tenderness to palpation. The patient's amylase, creatinine, electrolytes, and white blood cell count were normal. The liver function tests (LFT's) were unremarkable as well. The computed tomography (CT) of the abdomen with contrast revealed sigmoid diverticulitis. The patient was admitted to the hospital with a gastroenterology consultation.

The gastrointestinal (GI) consultant evaluated the patient and noted a colonoscopy six months prior with no significant abnormalities. They recommended bowel rest, intravenous (IV) fluid hydration, and analgesics. The GI polymerase chain reaction (PCR) was negative, and the patient was administered Zosyn. Twenty-four hours later, the patient developed some chills and fever overnight. The abdominal examination was unchanged. Infectious disease was consulted. The patient's temperature was 102.2, with a heart rate of 105.

Repeat laboratory studies showed a slight drop in the hemoglobin to 10.4. She had no overnight events and denied any bloody movements. The patient complained of a cough and sore throat. The chest x-ray was unremarkable. A Coronavirus (COVID-19) swab was obtained and came back positive. The patient showed no signs of hypoxemia and did not require advanced treatments. The medical team contemplated discharging for the following day. Over the next 24 hours, the patient's maximum temperature was 100.2. The rest of the vital signs were stable, and the examination was unchanged. The antibiotics were continued, and the patient was tolerating a soft diet. The patient's white blood cell count remained normal. The discharge occurred the next day. The medical team prescribed Augmentin for another three days.

No, in its determination of medical necessity, the health plan did not act reasonably, with sound medical judgment, nor in the patient's best interest. 

The requested health service/treatment of a full hospital admission was medically necessary for the patient. The patient was admitted to the hospital with an acute recurrent diverticulitis episode. She had taken five days of oral Ciprofloxacin at home, which provides decent antimicrobial coverage for this type of infection, and yet she continued to experience lower abdominal pain and had rectal bleeding with a fever. As a result, this is a failure of outpatient treatment. It was reasonable to admit the patient under an inpatient status, with an anticipated length of stay greater than 48 hours for administering IV antibiotics, bowel rest, IV fluid resuscitation, and cultures. The patient concurrently exhibited a COVID-19 infection, and it was reasonable to monitor for hypoxemia while receiving treatment for acute diverticulitis.

The health plans determination of medical necessity is overturned in whole.