Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis, Hyponatremia, Acute kidney injury.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient who presented to the Emergency Department (ED) with complaints of abdominal pain. The patient has a past medical history that includes diverticulitis as well as hypertension and a prior kidney stone. The patient indicated he felt like the symptoms were the same as diverticulitis complications he has had previously. The patient was placed on Cipro and Flagyl previously and told to undergo a computed tomography (CT) scan however he indicated he was feeling better and did not get imaging. The pain returned shortly after. He rated his pain at 4/10 and admitted to non-bloody diarrhea. 

The patient, on physical examination, had a temperature of 97.7 degrees with a heart rate of 82 beats per minute. The patient had a blood pressure of 108/59. There was minimal tenderness to palpation to the left upper and lower quadrant.  Bowel sounds were normal and there was evidence of costovertebral angle (CVA) tenderness bilaterally. The recommendation was made for laboratory and diagnostic studies. The laboratory studies revealed a sodium level of 126 with potassium of 3.2 and creatinine of 1.8. The patient's white blood cell count was 10.8 and total bilirubin was 6.1. Ultrasound revealed an enlarged liver demonstrating heterogeneous hyper echogenicity suggesting hepatic steatosis/hepatocellular disease. A CT scan revealed mild segments of mild sigmoid colonic wall thickening versus incomplete distention in the setting of diverticulitis the spleen was also moderately enlarged. The physician indicated the patient should be admitted for further treatment. 

The patient was admitted with the diagnoses of diverticulitis, hyponatremia, and acute kidney injury. It was recommended he receive intravenous (IV) hydration with Zosyn. He was also recommended to receive potassium and sodium and repeat labs the following day. The following day the patient did not have any significant new findings. The patient continued with additional monitoring and treatment and there were no further significant adverse events documented. The patient continued to improve and was transitioned to oral Augmentin. The patient was discharged on day 3 of admission with instructions to follow-up.

According to current literature, a patient may be admitted to inpatient services when there is evidence of hemodynamic instability such as persistent tachycardia, persistent hypotension, or a vital sign abnormality leading to inadequate system perfusion when there is evidence of peritoneal signs, persisting gross bleeding or evidence of a fistula, obstruction or perforation on imaging. Additionally, if there is severe pain requiring inpatient management, bacteremia, or vomiting that is severe persistent, the patient may be admitted as well. The submitted documentation indicated the patient was seen with complaints of abdominal pain. The documentation indicated the patient had recently taken antibiotics with improvement however the symptoms returned. This patient has several clinical features that required acute admission. There was evidence of severe hyponatremia and jaundice with a bilirubin of 6.1 likely related to sepsis. Therefore, the inpatient admission would be appropriate in this case to correct the above and continue monitoring for further decline.  

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.